Medical WO - Referrals Coordinator

Thundermist Health•Woonsocket, RI

15h•Hybrid

About The Position

The Referral-Prior Authorization Coordinator performs all functions necessary to process, obtain, and close referrals and prior authorizations in an accurate and timely manner. The coordinator will complete all documentation/forms and communicate information accurately to external providers/entities to ensure a high-quality patient experience. The coordinator will also maintain accurate records and update providers and patients as needed throughout the process.

Requirements

Minimum High School diploma or GED
Excellent communication skills
Must be proficient with the use of computers, answer multiple incoming telephone lines, take accurate written messages, verify all insurance coverages and files.
Strong communication skills both oral and written.
Ability to effectively manage change and adapt quickly
Accurate data entry skills and computer proficient
Ability to work independently and with a team
Ability to exercise judgment in dealing with sensitive, confidential information
Ability to handle a high volume of work in a demanding and fast-paced

Nice To Haves

Bi-lingual desired
Post-secondary training in Medical Assistant Program/Professional School preferred
1-year experience working with prior authorizations/referrals preferred
Knowledge of medical terminology (preferred)

Responsibilities

Process urgent and routine referrals/prior authorizations within expected timeframes
Meet with patients to schedule appointments, confirm preferred facility/specialist, update insurance, and assist with referral/prior authorization questions including providing proper documentation to patient
Advise patients of referral/prior authorization process and timeline
Recognize and utilize the preferred processes for specialists
Act as a liaison with pharmacies, insurers, and rendering facilities
Timely outreach to specialist offices/other to obtain consult notes following patient visits to close out pending referrals
Documentation in patient record regarding appointment date, consult note status, and prior authorization status updates
Monitor all referral/prior authorization queues, perform patient outreach, and identify barriers to bring referral/prior authorization to completion
Perform and clearly document appropriate patient outreach and action taken to ensure timely completion of referral/prior authorization
Responds by the end of the business day to incoming telephone encounters and voicemail queue in order to provide updates and bring issues to resolution
Clearly and concisely document actions taken in patient record
Provide patient with referral/prior authorization coordinator contact information to further assist with questions and/or the referral process
Outreach to specialist offices to inquire about services, determine wait times for visits, and to determine referral policies
Ensure that patient clearly understands the process, expectations, and timeline of the office to which they are being referred
Obtain required documents (i.e., labs, DI, progress notes, etc.,) from EMR for attachment to prior to sending
Able to obtain required records (i.e., consult notes, DI, labs, etc.) from external resources utilizing (i.e., Cerner, Life Links, Landmark, Current Care, etc.) electronic and other resources to attach to referral
Create, update, and/or change referral/prior authorization at provider request
Obtains insurance referral and notes authorization number, dates, and total # of visits allowed prior to sending referral
Fax clinical notes to insurer when prior authorizations are initiated for patients from another facility
Monitor’s queues for prior authorization approval letters then faxes or calls rendering facility, pharmacy, and/or patient with approval information
Monitor faxes for pharmacy denials and reviews patient records and/or contacts patient to verify list of failed medications, checks plan formulary, confers with THC pharmacist or pharmacy for alternatives for provider approval/denial
Inform provider/prescriber of denials to determine if an appeal should be submitted and submit appeal if determined appropriate with all accompanying documentation
Prepares responses to authorization denials within an appropriate timeframe
Monitor eCW to verify fax confirmations; resend failed faxes
Research provider information (NPI, address, phone/fax) and CPT codes for out of network for medical prior authorization requests
For patients with Medicare Part D, contact plan or pharmacy to verify the correct plan and ID number
Closes duplicates and completes process in an open request
Follows standardized workflows to enable continuity and cross coverage