Referral Clerk

Katmai • Fort Carson, CO

5h

About The Position

The Referral Clerk provides consultation and administrative support to TRICARE beneficiaries and helps optimize patient flow by assisting the CMHS Referral Management Team, including the Central Referral Center (CRC) and MTF Referral Management Centers, with processing specialty-care referrals. The role reviews referrals for appropriateness and completeness, routes them to the appropriate place of care, provides health-benefits advice, and maintains referral records. It applies utilization review (UR) and utilization management (UM) principles and established guidelines to support quality, cost-effective specialty care. The Referral Clerk also coordinates Right of First Refusal (ROFR) referrals and works with case managers when cases may benefit from alternative levels of care.

The position supports referral-center customer service and communications among beneficiaries, referral centers, internal staff, providers, network and outside providers, and ancillary healthcare workers. It reviews and analyzes collected data, prepares reports on resource utilization patterns, disseminates information to government team members and multidisciplinary hospital committees, and uses information systems to develop, analyze, update, and record data. The role also helps integrate UM review policies and procedures into operations and interfaces with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as needed.

This is a full-time position. Additional hours may be required to complete an assignment or project. Work is performed primarily in a professional office setting using standard office equipment. The position has no supervisory responsibilities and requires no travel or driving.

Requirements

• High school diploma or GED equivalency.
• Basic Life Support (BLS) course completed through the American Heart Association or American Red Cross.
• At least three years of clinical experience.
• Working knowledge of computers, including the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.
• Proficiency with current versions of office-automation software relevant to the role.
• Knowledge of professional nursing procedures.
• Working knowledge of EHR Genesis and MCSC databases.
• Ability to read, understand, speak, and write English well enough to communicate effectively.
• Ability to obtain and maintain any necessary security access and/or background checks.

Nice To Haves

• Knowledge of medical terminology.
• ROFR knowledge in the area of health benefits.
• Knowledge of general medical ethics and health-records administration.
• Excellent communication and customer-service skills.

Responsibilities

• Review collected data to identify areas requiring intensive management; analyze data and prepare reports on resource utilization patterns; and disseminate information to government collaborative-team members and multidisciplinary hospital committees.
• Coordinate specialty-care referrals by reviewing them for appropriateness and completeness and routing them to the appropriate place of care.
• Provide patients with health-benefits advice as a functional expert in that area.
• Maintain and track referral records.
• Participate with referral centers in providing, assessing, and improving customer service and relations.
• Manage communications among beneficiaries, referral centers, internal staff, providers, network and outside providers, and ancillary healthcare workers.
• Apply utilization review (UR) and utilization management (UM) principles when processing specialty referrals.
• Plan and perform specialty-referral reviews according to established guidelines to support quality, cost-effective care.
• Conduct first-level reviews of all specialty-care referrals.
• Facilitate professional and patient-care activities.
• Coordinate with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as needed to ensure referrals are appropriate.
• Identify cases that may benefit from alternative levels of care and involve the case manager as needed.
• Plan and prioritize utilization-review activities so identified patient needs are addressed promptly.
• Use information systems to develop, design, analyze, update, and record data.
• Facilitate development and integration of UM review policies and procedures into operations.
• Perform Right of First Refusal (ROFR) coordination of specialty-care referrals.
• Maintain regular and punctual attendance.
• Perform other duties as assigned.

Benefits

• Medical, dental, vision, life, and AD&D insurance.
• Long-term and short-term disability insurance.
• 401(k) savings plan.
• Employee Assistance Program (EAP).
• Vacation and paid personal time.
• 11 paid federal holidays.
• Leave of absence.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED