Referrals Specialist

Description

POSITION SUMMARY

Promotes timely and appropriate referrals for health care services by assisting clinical staff in the processing of prior authorization requests for ambulatory services and elective inpatient admissions.

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.

RESPONSIBILITIES

• Maintains internal operations and compliance with established standards and timelines by receiving outpatient referral authorization requests via online, , fax, or telephone - mail; determining member eligibility (CMC, Medi-Cal or Medicare) and reviewing plan benefits; checking and  entering appropriate CPT and/or ICD codes and referral information in the Utilization/Case Management system; review referrals against the No Prior Authorization List and authorize Referrals based on the L1 Scope.  If not approved by L1, referral request will be forwarded to the assigned clinical staff for review following policies and procedures; obtaining additional clinical documentation from primary care provider or specialist, as requested by clinical staff;
  • Tracking and assisting claims re-routes, appeals,
  • Processing denial letters.

• process has been extended to incorporate the translation of the denial language in the seven (7) threshold languages.
  • Review and monitor CBAS (Community Based Adult Services) authorization requests
  • Process and track LOA (Letters of Agreements) requests and create an Extension Letter (Delay Letter)

• This process has been extended to incorporate the translation of the denial language in the         seven (7) threshold languages.
  • Process and track PT home evaluations for power mobility devices and DME items needing evaluation.  This process includes generating additional authorization for the PT vendor and entering in the PT vendor’s portal new request for each case.
  • Process Extension letters for PT evaluations and when additional information is needed,

• This process has been extended to incorporate the translation of the denial language in the seven (7) threshold languages.
  • Enter NEMT requests for transportation in the NEMT portal.
  • Provide oral notification on all Urgent CMC authorizations and create manual notification letters for these cases on Fridays.  Monitor Oral Notification Log.
  • Monitor the CMC Authorization Notification Report to identify and letters that were not sent via the external printing company.  If letters are not sent via the external printing company, generate manual notification letters and send to members.
  • Review for CCS (California Children’s Services).
  • Process internal request for CS services
  • Process Online requests for ECM services
  • Process Case Management requests (DME, Transportation, field auths).
  • Run Daily Pend Report to ensure compliance for TAT
  • Review and file the PDF Letters and Excel Spreadsheets received daily from SD Printers.
  • Train other L1 Staff on Daily Tasks and Authorization Review processes

• Provides customer services to external/internal customers by assisting Community Health Group (CHG) contracted facilities, primary care provider sites, specialty and ancillary providers, and members and their families with information regarding access to health care services; utilizing clinical staff as a resource, reviewing plan benefits and prior authorization requirements with customers; educating health care providers regarding utilization management process; providing information about special program and community services and transferring callers to other appropriate staff members as necessary; producing and mailing hard copy responses, including non-certified and exhaustion of benefit letters, facility and members as applicable.
• Assists clinical staff by reporting medical care delivery issues to clinical supervisor; identifying potential over- or under-utilization of services, and gathering data obtained from daily referrals review to assist in reporting primary and specialty care practice patterns; reviewing appropriate coding of services and use of Community contracted providers; referring questionable referrals for clinical review; assisting clinical staff with educating primary care providers.
• Facilitates timely referral turnaround by receiving completed referral requests from facility or clinical staff; entering data and faxing or calling authorization to appropriate provider.
• Ensures the provision of quality health care by monitoring, in conjunction with clinical staff, member and provider concerns; Potential Quality Issues (PQI), assisting in resolving problems involving access to appropriate levels of care; completing CQI forms and requesting reports; maintaining confidentiality.
• Contributes to the team effort by attending department meetings; giving and receiving feedback; accomplishing related results as needed; assisting clinical staff in identifying areas requiring policies and procedures; working with clinical staff in policy development and periodic policy review.
• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

Qualifications

EDUCATION

• High school diploma or equivalent.
• Medical terminology.
• Associates degree in medical field preferred.

EXPERIENCE/SKILLS                                                          

• 2 years customer service and data entry experience in medical field.
• 3 years customer service and data entry experience in a managed care organization preferred.
• Ability to operate a personal computer, UM/CM System/HSD database, telephone, fax, and copier.
• Medical terminology including ICD-10 & CPT coding structures.
• Excellent customer service and communication skills.
• Detail-oriented.
• Bilingual (English/Spanish) preferred.

PHYSICAL REQUIREMENTS

• Prolonged sitting, data entry and telephone use.
• May be required to work evenings and/or weekends.

The above statements are intended to describe the general nature and level of work being performed.  They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

Salary : $20 - $22