Referrals Specialist

Description

SUMMARY:

Applicant must possess a High School diploma or equivalent. A minimum of 1-year experience in a healthcare setting to include front office and knowledge in referral authorization, health insurance eligibility, and data entry. Reviews the utilization of hospital resources against established criteria documentation requirements of external agencies.  Monitors and evaluates the medical necessity, appropriateness, and efficient use of health care services.  Provides reports and recommendations to medical and hospital staff for improved utilization of resources and to maximize reimbursement while maintaining quality care.  Must be able to work with the Indian Community, and be sensitive to the Indian Culture and its needs.

MAJOR DUTIES AND RESPONSIBILITIES:

1. Performs reviews of inpatient medical records to determine admission level of care and continued stay appropriateness.
2. Coordinates with other hospital departments such as social services, business office, and patient registration in matters of review decisions, discharge planning, and fiscal communications.
3. Appropriately reports quality, infection control, and risk issues found during record reviews.
4. Coordinates closely with the physician advisor, referring cases that do not meet criteria and determining corrective action plan on utilization problems.
5. Acts as the hospital liaison with Medicare PRO, commercial payers, and other external review agencies.
6. Compiles and analyzes data for utilization management activities.  Maintains logs and statistics.
7. Provides education to hospital and medical staff regarding utilization management.
8. Maintains professional growth and development.  Keeps current on utilization review rules, regulations, and policies.
9. Acts as system manager for MIS information system and department advisor on automation issues.
10. Maintain filing and reference systems for Utilization Review Department.
11. Performs other related duties as assigned or requested.

Qualifications

Education:                            

High School graduate or equivalent (GED)

Experience:

A minimum of 1-year experience in a healthcare setting to include front office and knowledge in referral authorization, health insurance eligibility, and data entry.

Knowledge of:                      

DRG and ICD-9 coding; working knowledge of ISD-A criteria and Medicare regulations.  Knowledge of computer operation, medical terminology, ICD-9, and CPT Coding.       

Skill:            

Type 35 wpm, moderate computer skills, good communication skills, both written and verbal required.

Ability to:                              

Must be able to work with the Indian Community, and be sensitive to the Indian culture and its needs. 

Must be able to work on weekends which may be required once in a while depending on workload and clinic hours.

Clinic Location: 

Morongo Indian Health Clinic (11555 ½ Potrero Banning, Ca 92220)

Salary : $21