Referral Specialist I/Patient Access (Pre & Prior Authorizations, Appeals, Insurance) - Paragon Infusion

Elevance Health • Plano, TX

1d • Hybrid

About The Position

Referral Specialist I/Patient Access (Pre & Prior Authorizations, Appeals, Insurance) - Paragon Infusion Location: 3033 W President George Bush HWY., STE 100, Plano, TX 75075 A proud member of the Elevance Health family of companies, Paragon Healthcare brings over 20 years in providing life-saving and life-giving infusible and injectable drug therapies through our specialty pharmacies, our infusion centers, and the home setting. The Referral Specialist I is responsible for providing support to a clinical team in order to facilitate the administrative components of clinical referrals. How You Will Make an Impact Primary duties may include, but are not limited to: Ability beyond intake calls that include verifying eligibility and benefits for medical and pharmacy payers through multiple methods for specialty chronic and acute therapy services. Acts as liaison between patients, healthcare providers, infusion centers, pharmacy, and billing department to address issues. Ability to review and interpret clinical records to ensure the patient meets medical policy guidelines for coverage, for completeness, and performs follow-up for additional information if necessary. Ability to initiate pre-determination, prior authorizations, and appeals for denials based on payer policy. Ability to read and interpret payer contracts, and payer policies to effectively manage referrals and mitigate risk of accounts receivable. Maintain knowledge of therapies serviced by Paragon, at minimum, therapy and diagnosis correlation and patient information required. Contacts physician offices as needed to obtain demographic information or related data. Manage referrals, documents communications, actions, and other data in the system.

Requirements

• Requires HS diploma or GED and a minimum of 1 year of experience in a high-volume, interactive customer service or call center environment; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

• 1 year of experience in healthcare reimbursement, billing, or patient access, with specific experience in infusion therapy strongly preferred.
• Advanced knowledge of HCPCS, NDC, CPT, and ICD-10 coding for referral management is strongly preferred.
• Advanced knowledge of Medicare Local Coverage Determination is strongly preferred.
• Knowledge of insurance verification, pre-authorization, and claims submission process is strongly preferred.
• Strong mathematical, analytical, and problem-solving skills.
• Proficiency in computer skills, including electronic health record systems and Microsoft Office suite.
• An associate or bachelor’s degree is preferred but not required.
• Ability to work independently and collaboratively.
• Ability to maintain professionalism and confidentiality.

Responsibilities

• Ability beyond intake calls that include verifying eligibility and benefits for medical and pharmacy payers through multiple methods for specialty chronic and acute therapy services.
• Acts as liaison between patients, healthcare providers, infusion centers, pharmacy, and billing department to address issues.
• Ability to review and interpret clinical records to ensure the patient meets medical policy guidelines for coverage, for completeness, and performs follow-up for additional information if necessary.
• Ability to initiate pre-determination, prior authorizations, and appeals for denials based on payer policy.
• Ability to read and interpret payer contracts, and payer policies to effectively manage referrals and mitigate risk of accounts receivable.
• Maintain knowledge of therapies serviced by Paragon, at minimum, therapy and diagnosis correlation and patient information required.
• Contacts physician offices as needed to obtain demographic information or related data.
• Manage referrals, documents communications, actions, and other data in the system.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

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