Health Management Referral Coordinator

Martin's Point Health Care • Portland, ME

396d

About The Position

The Health Management Referral Coordinator at Martin's Point Health Care is responsible for coordinating and processing out-of-network referral, authorization, and appeal requests. This role serves as a liaison between members and the health plan, ensuring access to care within health plan guidelines. The Coordinator provides administrative support to the Health Management Department and collaborates with various staff to facilitate timely and appropriate care for members.

Requirements

• Associate degree or equivalent education and experience
• 2 years of managed care experience including experience in a call center
• Experience with medical terminology, CPT, ICD-10, and HCPCS coding is a plus

Nice To Haves

• Medical Assistant Certification
• Basic knowledge of CMS and NCQA regulations

Responsibilities

• Available on a phone queue from 8 a.m. to 4:30 p.m. to receive referral and/or authorization requests and answer questions from members and providers.
• Assemble information concerning patient's clinical background and referral needs, providing appropriate clinical information to Utilization Review Nurses.
• Make outbound calls to obtain supporting documentation from referring providers and specialists regarding care requests.
• Research information to find similar specialists contracted with the member's plan for out-of-network specialty care.
• Review details and expectations about the referral with members.
• Coordinate scheduling with participating specialists to ensure timely care and adherence to access standards.
• Ensure referrals are addressed in a timely manner per contractual and regulatory standards.
• Manage assigned referral/authorization queues by reviewing, entering, and processing care requests according to guidelines.
• Upload faxes and required information into the medical management system.
• Track out-of-network referrals for network follow-through.
• Comply with all contract requirements and organizational standards regarding referrals, authorizations, and communications.
• Participate in Health Management Department meetings and contribute to process improvement initiatives.

Benefits

• Organizational culture of trust and respect
• Continuous learning opportunities
• Supportive work environment
• Recognition as a 'Great Place to Work' since 2015

What This Job Offers

• Job Type: Full-time
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree