Medical Referral Specialist

Pokagon Band of Potawatomi Indians•Dowagiac, MI

About The Position

Serve clients and the community by gathering and filing the necessary information to provide a referral track to access eligible providers within the Preferred Provider Network (PPN). Provide leadership and act as an advocate for Tribal Citizens in the effective utilization of alternate health resources. Ensure that all possible alternative coverage have been explored and exhausted before assuming responsibility of “Payer of Last Resort.”

Requirements

Associate degree in a health care related discipline with a minimum of one (1) year medical referral experience is required.
In lieu of this requirement, willing to consider either: 1. three (3) years medical referral experience without an associate's degree Or 1. One (1) year of healthcare support experience at Pokagon Health Services.
Must have the ability and skill to interview patients in-depth, to determine eligibility/viability of alternate funding potential.
Strong delivery of positive service and good communication skills, both oral and written.
Excellent communication and interpersonal skills, and the ability to speak effectively and respond to questions.

Nice To Haves

Bachelor's degree in health care administration preferred.
Experience with EPIC EMR preferred.
Prior experience in the development of provider networks, referral protocols, electronic health records, and alternative health care programs and funding requirements.

Responsibilities

Serve clients by taking physician referral orders and mapping them to the appropriate providers who would be active and available within the Preferred Provider Network (PPN). Schedule outside medical appointments with the Pokagon Transportation department when appropriate using EHR scheduling functionality.
Coordinate insurance coverage with various programs that are available within the service area with the appropriate administrative coding and billing information to ensure an effective cycle of in-network referrals, service delivery and claims administration for the client.
Obtain prior authorization from insurance companies when appropriate.
Optimize workflow by promptly routing orders for Medical Care Review Committee (MCRC) approval and expediting subsequent actions such as referral coordination or denial notifications.
Provide out-reach initiatives if there are coverage voids within the PPN, given the network’s dynamic nature and constant potential for market adaptation.
Apply knowledge of insurance program offerings, coverage, provider capabilities, and process knowledge needed to qualify clients for program participation.
Act as a liaison between clients, clinic providers, Purchased /Referred Care (PRC) Business Office, Registered Health Information Technicians and the Business Manager.
Verify client documentation for completeness and accuracy and return to patient registration if gaps are identified.
Assess client understanding of the PPN, referral process and follow-up responsibilities to facilitate a smooth and timely service delivery cycle process.
Determine eligibility of clients for direct care and PRC based upon registration information according to IHS and Band guidelines.
Maintain all HIPPA security by following procedures, securing sensitive data and monitoring logbooks. Maintain total client confidence and protect operations by keeping necessary medical information confidential.