Referrals Specialist Job at Gonzaba Medical Group
Summary: 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.
Duties:
- 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 turn around 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
- Demonstrate excellent customer service: Assist patients and staff to set up services or resolve concerns.
- Must be able to clearly communicate with referral team, Keep PCP and, clinical staff informed of pertinent findings/issues uncovered.
- Document appropriately in GMG computer systems, and other associated systems.
- Successfully meet production goals.
- Able to work efficiently under pressure.
- Maintain strict confidentiality.
- Other duties as assigned.
Education and Experience: Minimum high school education or equivalent. Previous experience in managed care referrals. MA Certificate preferred. Some college business courses preferred. Must be able to use basic office equipment. Must have knowledge of ICD-10 and CPT-4 coding, medical terminology and detail oriented. Must have excellent customer service skills.
Computer Skills: Knowledge of Word Processing software, database software, spreadsheet, and Internet software.
Supervisory Responsibilities: This job has no supervisory responsibilities.
Work Environment: Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.
Physical Demands: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting to 40 lbs. Close vision and ability to adjust focus.
The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Reasonable accommodations may be made to enable otherwise qualified individuals with disabilities to perform the essential functions of the job.
Please Note :
bankofmontserrat.ms is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, bankofmontserrat.ms provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.