Referrals Specialist

Gonzaba Medical Group•San Antonio, TX

2d•Onsite

About The Position

The Referral Specialist focuses on the internal GMG referral processes, obtaining authorization from health plans and other UM entities for referrals, obtains LCD/NCD (Local and National Coverage Determination) from Medical Coverage Database and communicating the outcome to patients, specialists, and other providers. This role seeks to enhance appropriate utilization by using GMG services and preferred providers for medically necessary care.

Requirements

All duties performed will be done accurately and in a timely manner.
Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
Ensures customer service is always maintained at the highest level.
Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
Participates in educational programs as needed.
Maintains strictest member and company confidentiality.
Minimum high school education or equivalent.
Previous experience in managed care referrals.
Must have knowledge of ICD-10 and CPT-4 coding, and medical terminology.
Skilled in use of computer/EMR systems.
Knowledge of Word processing software, spreadsheet software, Internet, and database software.

Nice To Haves

Medical Assistant Certificate preferred.
Bilingual English/ Spanish fluency preferred.

Responsibilities

Run daily referral reports to create work list and monitor referrals in process.
Research chart for supporting documents and process referrals according to departmental goals, and accepted protocol, including referrals from internal GMG system, fax and mail from health plans, specialists, and other providers.
Verify insurance eligibility and benefits from HMO eligibility lists or by contacting insurance companies by phone when needed.
Ability to review a high volume of referral cases with CMO telephonically, enter referral information in the computer system using correct coding procedures (LCD/NCD (Local and National Coverage Determination).
Document sufficient referral detail so it is clear what was requested, what occurred, what was approved, and who was notified.
Notify patients of the referral process, authorization decisions, and verify their understanding.
Notify referral provider of authorizations in a timely manner.
Conducts periodic review of previously authorized ongoing care for continued need and or eligibility.
Notify supervisor of problem referrals where turnaround goals are exceeded, or other issues are encountered.
Acts as liaison for Managed Care and PCP when patient has questions.
Serves as clinic information source regarding managed care and referrals.