Referral Specialist

Renown Health•Reno, NV

About The Position

The Referral Specialist processes authorization requests accurately and promptly in accordance with federal, state, and accreditation guidelines. The role includes entering information received by phone, fax, or electronically; verifying member eligibility and benefit coverage; checking coordination-of-benefits information; communicating plan benefits and exclusions to physician offices; and collecting pertinent clinical documentation. The specialist works with Care Coordinators and Case Managers to support appropriate resource use, timely treatment, and quality of care. The position also supports patient communication, pre-registration, appointment scheduling, and payment collection as needed. The role manages authorization requests and related oral and written communications, gathering, tracking, and documenting requests received by phone, fax, mail, or electronically. It validates eligibility and benefit coverage to help ensure requested services are covered and authorized, and keeps department leadership informed of customer feedback to support process improvement. The position serves as a liaison among Hometown Health, Renown, health care providers, and health insurance carriers in a fast-paced environment using telephones, email, fax, and instant messaging. The Referral Specialist does not make medical-necessity determinations and does not provide patient care. Permitted activities related to authorization management are limited to checking service requests for completeness, collecting and transferring non-clinical data, requesting medical records to obtain structured clinical data, and other activities that do not require evaluating or interpreting clinical information.

Requirements

High school graduation or GED.
Working-level knowledge of English, including reading, writing, and speaking.
At least one year of experience working in a medical office, hospital, health care billing, or health insurance company.
Working knowledge of insurance products, including HMO, PPO, self-funded, and Medicare Advantage plans.
Excellent written and verbal communication skills.
Ability to process large amounts of information.
Ability to work efficiently under stress and deadlines.
Knowledge of medical terminology.
Ability to assess situations, consider alternatives, and choose an appropriate course of action.
Ability to work in a fast-paced environment with constant interruptions.
Ability to manage multiple priorities and consistently meet department service and productivity goals.
Knowledge of ICD-10 and CPT diagnosis and procedure codes, with a high level of accuracy.
Ability to organize and process work efficiently to meet deadlines.
Knowledge of HIPAA and/or The Joint Commission standards.
Proficiency with Microsoft Office Suite, including Outlook, Excel, and Word.
Ability to complete online learning requirements, access online forms and policies, and complete online benefits enrollment.
No license or certification is required.

Responsibilities

Process authorization requests accurately and promptly in accordance with federal, state, and accreditation guidelines.
Enter information received by phone, fax, or electronically.
Verify member eligibility, benefit coverage, and coordination-of-benefits information.
Communicate members’ plan benefits and exclusions to physician offices.
Collect pertinent clinical documentation and request medical records as needed.
Work with Care Coordinators and Case Managers to support appropriate resource use, timely treatment, and quality of care.
Provide patient communication, pre-registration, appointment-scheduling support, and payment collection as necessary.
Gather, track, and document authorization requests received by phone, fax, mail, or electronically.
Manage oral and written communications related to authorization requests.
Validate eligibility and benefit coverage to ensure requested services are covered.
Keep department leadership informed of customer opinions and viewpoints to support continuous process improvement.
Serve as a liaison among Hometown Health, Renown, health care providers, and health insurance carriers.
Perform only non-clinical authorization activities, including checking requests for completeness and collecting or transferring non-clinical data; do not evaluate or interpret clinical information or make medical-necessity determinations.