Prior/Auth. Referral Specialist

STERLING HEALTH SOLUTIONS INC•Mount Sterling, KY

1d•Onsite

About The Position

Assists in the prior authorization/referral process under the direction of the CMO, Director of Quality, providers, and clinical care teams. Care is delivered most efficiently when team members function at the maximum of their licensure, skill-set, and abilities. Team members are expected to recognize the roles that others on the team play and follow the organizations established protocols for team-based care. SHS’s goal of the Care Teams is to Improve Patient Health and Outcomes and Maintain High Provider, Staff and Patient Satisfaction. Clear communication between team members is critical. Team members will communicate routinely through electronic information flow as well as minute-to-minute communication through brief verbal interactions, and I2I Population Health. SHS’s Care Teams are comprised of the Provider as the lead, Clinical Support Staff (CMA/LPN/RN), Prior Authorization/Referrals, Patient Navigators, Triage, Registrars, Schedulers and Medical Records. Outreach Associates and Drug Assistance Coordinators may also be part of specific patients’ care teams.

Requirements

Maintain patient confidentiality at all times
Be courteous and respectful to patients and co-workers at all times
Ability to work effectively with providers, staff, and third-party payors
Ability to work independently, establish priorities, and coordinate work activities
Ability to work under pressure
Ability to use good judgment to accomplish goals
Ability to identify and access resources
Ability to communicate effectively with a diverse group of individuals
Knowledge of the community/population served
Ability to “empower” clients – identify problems and resources to help them solve problems themselves
If Bilingual interprets as needed.
High School Diploma or GED
On-the-job Training
Proficient in Windows and Microsoft applications (Word, Excel, Power Point & Outlook).
Computer skills in electronic health and medical records.

Responsibilities

Is proactive in assisting the provider.
Maintain ongoing tracking and appropriate documentation of prior authorization/referrals using i2i Tracks.
Assists patients in answering routine questions, resolving minor difficulties and giving directions to patients as authorized by the Provider. Documents all phone conversations in patient’s EMR chart to include any Provider directed instructions.
Provides education and support to patients and families as directed by the Provider.
Makes appointments as needed and directed by the Provider through the referral process.
Ensures that prior authorizations and referrals are addressed in a timely manner.
Coordinates use of interpreting services for non-English speaking patients.
Processes prior authorizations and referrals, phone notes and fax orders for patients.
Follows established regulations and professional standards as required of the position. Participates in and supports continuous quality improvement.
Identify and utilize cultural and community resources. Establish and maintain relationships with identified service providers.
Other duties and responsibilities as assigned by management.