Under the direction of the Health Services Manager, this positionÆs primary function is to process referral requests. The responsibilities of the Referral Specialist include: data entry of referrals, verification of eligibility, gathering and updating of COB information, explanation of benefits to physician offices and collection of pertinent clinical information. The Referral specialist works closely with the Case Managers to provide appropriate utilization of resources, timeliness of treatment and quality of care for HTH members. The Referral Specialist does not make medical necessity determinations.
Nature and Scope:
Responsibilities of the Referral Specialist include:
1. Maintains detailed records of information gathered and authorizations issued and extended: this is done by entry into the DST/Health Connect systems.
2. Assists in identifying and data gathering for potential COB cases.
3. Responsible for production of authorization letters to providers, members and facilities from the DST system.
4. Participates in Provider Education regarding Health Services policies and procedures.
5. Performs other duties as required to meet departmental goals.
Knowledge, Skills & Abilities:
1. Excellent written and verbal communication skills.
2. Ability to process large amounts of information.
3. Ability to assess a situation, consider alternatives and choose the appropriate course of action.
4. Working knowledge of managed care philosophy and familiarity with acronyms.
5. Ability to work in a fast paced environment with constant interruptions.
6. Ability to ICD-9 and CPT code diagnosis and procedures with a high level of accuracy.
7. Strong organizational skills.
Under no circumstances shall Referral Specialist staff perform any activities related to the appeal management process other than:
â•– Performance of review of service request for completeness of information
â•– Collection and transfer of non-clinical data. Such data may include demographic information, employer name, insurance information, date of surgery, physician name, facility name, etc.
â•– Acquisition of structured clinical data in the form of medical records requests
â•– Activities that do not require evaluation or interpretation of clinical information
This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications: Requirements – Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English. Graduation from an accredited Medical Assistant program preferred.
Requires at least one yearÆs experience in data entry/computers and/or customer service. Medical terminology preferred. ICD-9 and CPT coding experience preferred.
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.