Pre-Service Coordinator

Humana • Miramar, FL

1d • Remote

About The Position

The Pre-Service Coordinator is responsible for all aspects of referral management and accurately process incoming requests for homecare, DME/supplies and pharmacy/infusion services meeting the timeline expectations as outlined in the Health Plan contractual agreements. The Pre-Service Coordinator will review inbound referrals and correspondence for processing, fulfilment or resolution utilizing all appropriate software systems and resources. Screen physician’s orders and documentation to identify that all qualifying medical documentation and required information is included. When necessary, request additional applicable information from referring entity. Perform verification of benefits coverage and eligibility for services per Health Plan contract. Review referral data matching it against specified medical terms and diagnoses or procedure codes and follow established procedures for approving request or referring request for further review. Provide referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Communicate with patient to confirm demographics and explain the details of the services/care requested. Coordinate the timely delivery of care and services with providers. Also communicate with referring entities, providers, and members regarding final referral determination while maintaining detailed documentation to record patient, physician, referral source and provider interactions and communications. Work with Pre-Authorization, Utilization Management, Billing, Pharmacy, Home Care and DME regarding referred services. Maintain working knowledge of applicable CPT, HCPC, ICD-10 codes, and all insurance contracts. Understand Medicare/Medicaid criteria and Health Plan policies to ensure the referral meets all requirements and guidelines. Maintain knowledgeable of, and adhere to applicable federal/state regulations, laws related to patient confidentiality, release of information, and HIPAA. Always preserve the security and confidentiality of patients’ personal information. Report ongoing issues with referring entities or providers that delay service delivery to manager. Provides excellent internal and external customer service by ensuring work meets quality standard. Use your skills to make an impact

Requirements

• 1-3 years of Home Health, DME (Durable Medical Equipment), or Infusion Pharmacy experience is required.
• Knowledge of Medicare/Medicaid & commercial insurance is required.
• Experienced with medical authorizations is required.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Excellent customer service and communication skills.

Nice To Haves

• Wound care/Ostomy supplies experience is preferred.
• Microsoft Office technical experience with Word, Outlook, and Excel is preferred.
• Knowledge of medical billing is preferred.

Responsibilities

• Responsible for all aspects of referral management
• Accurately process incoming requests for homecare, DME/supplies and pharmacy/infusion services meeting the timeline expectations as outlined in the Health Plan contractual agreements
• Review inbound referrals and correspondence for processing, fulfilment or resolution utilizing all appropriate software systems and resources
• Screen physician’s orders and documentation to identify that all qualifying medical documentation and required information is included
• Request additional applicable information from referring entity when necessary
• Perform verification of benefits coverage and eligibility for services per Health Plan contract
• Review referral data matching it against specified medical terms and diagnoses or procedure codes and follow established procedures for approving request or referring request for further review
• Provide referral management education to members and providers regarding medical benefits, referral status and prior authorizations
• Communicate with patient to confirm demographics and explain the details of the services/care requested
• Coordinate the timely delivery of care and services with providers
• Communicate with referring entities, providers, and members regarding final referral determination while maintaining detailed documentation to record patient, physician, referral source and provider interactions and communications
• Work with Pre-Authorization, Utilization Management, Billing, Pharmacy, Home Care and DME regarding referred services
• Maintain working knowledge of applicable CPT, HCPC, ICD-10 codes, and all insurance contracts
• Understand Medicare/Medicaid criteria and Health Plan policies to ensure the referral meets all requirements and guidelines
• Maintain knowledgeable of, and adhere to applicable federal/state regulations, laws related to patient confidentiality, release of information, and HIPAA
• Preserve the security and confidentiality of patients’ personal information
• Report ongoing issues with referring entities or providers that delay service delivery to manager
• Provide excellent internal and external customer service by ensuring work meets quality standard

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees