Referrals Specialist

COMMUNITY HEALTH GROUP•Chula Vista, CA

6d•$21 - $24•Onsite

About The Position

Promotes timely and appropriate referrals for health care services by assisting clinical staff in processing prior authorization requests for ambulatory services and elective inpatient admissions. Works with relevant departments to ensure processes, programs, and services are completed efficiently and in accordance with company policies and applicable state and federal regulations, including CMS and/or Medicare Part D, DHCS, and DMHC requirements. The role processes and tracks outpatient referrals and authorization requests, supports customers seeking access to health care services, facilitates referral turnaround, and assists clinical staff with utilization management, quality concerns, and policy development. It also performs related administrative, notification, documentation, and team support duties.

Requirements

High school diploma or equivalent.
Medical terminology knowledge, including ICD-10 and CPT coding structures.
At least 2 years of customer service and data entry experience in a medical field.
Ability to operate a personal computer, UM/CM system or HSD database, telephone, fax, and copier.
Excellent customer service and communication skills.
Detail-oriented.

Nice To Haves

Associate degree in a medical field.
At least 3 years of customer service and data entry experience in a managed care organization.
Bilingual in English and Spanish.

Responsibilities

Receive outpatient referral authorization requests through online channels, fax, telephone, or mail; determine member eligibility and review plan benefits.
Enter appropriate CPT and/or ICD codes and referral information into the Utilization/Case Management system; review requests against the No Prior Authorization List and authorize referrals within the L1 Scope, forwarding other requests to clinical staff for review.
Obtain additional clinical documentation from providers as requested by clinical staff.
Track claims re-routes and appeals, and process denial letters, including translation of denial language into the seven threshold languages.
Review and monitor CBAS authorization requests; process and track Letters of Agreement and create extension or delay letters.
Process and track physical therapy home evaluations for power mobility devices and DME items requiring evaluation, including vendor authorizations and portal requests; process evaluation extension letters and requests for additional information.
Enter NEMT transportation requests in the NEMT portal; process CCS reviews, internal CS service requests, online ECM service requests, and Case Management requests for DME, transportation, and field authorizations.
Provide oral notification for urgent CMC authorizations, prepare manual notification letters when required, and monitor oral notifications and authorization notification reports.
Run the Daily Pend Report to monitor turnaround-time compliance; review and file daily PDF letters and Excel spreadsheets received from SD Printers.
Train other L1 staff on daily tasks and authorization review processes.
Assist contracted facilities, primary care sites, specialty and ancillary providers, members, and families with information about access to health care services, plan benefits, prior authorization requirements, utilization management, and community programs.
Produce and mail hard-copy responses, including non-certified and exhaustion-of-benefit letters, to facilities and members as applicable.
Report medical care delivery issues to clinical supervisors; identify potential over- or under-utilization, gather referral data for practice-pattern reporting, review coding and use of contracted providers, and refer questionable requests for clinical review.
Receive completed referral requests, enter data, and fax or call authorizations to the appropriate provider.
Monitor member and provider concerns and potential quality issues with clinical staff, help resolve access-to-care problems, complete CQI forms, request reports, and maintain confidentiality.
Attend department meetings, exchange feedback, assist clinical staff in identifying policy and procedure needs, contribute to policy development and review, participate in committees and meetings, and perform other assigned duties.