Sr. Referral Specialist

Duly Health and Care • Lisle, IL

5d • $18 - $27

About The Position

Under the direction of the Non-Cap Managed Care Services Manager and Supervisor, the Senior Referral Specialist is responsible for a high volume of incoming calls from Physician Offices. The Senior Referral Specialist is responsible for processing internal and external referrals requests which includes but is not limited to; obtaining and submitting medical records, verification of eligibility, obtaining benefit coverage determinations, providing network steerage and referral issue resolution. These activities are designed to support the delivery of quality, appropriate health care and health care promotion for all patients.

Requirements

• High School diploma
• Strong customer service focus
• Effective verbal and written communication skills
• Teamwork orientation
• Organized and able to manage competing priorities
• Good judgment
• Resourcefulness in problem solving
• Able to take and follow through with delegated tasks and accountability
• Medical Terminology Knowledge
• Service Orientation: Capable of providing excellent service to customers, displays a friendly and approachable demeanor, works to resolve customer complaints, and understands customer service principles.
• Organization: Able to provide order and structure to daily processes and work environment.
• Verbal Communication: Talking to others to convey information effectively
• Written Communication: Able to write clearly and legibly
• Informational Ordering: The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., numbers, letters, words, etc.)

Nice To Haves

• Prefer working knowledge of Epic.
• Experience with Microsoft Office/Outlook

Responsibilities

• Ensures coverage of medical services through gathering information from the physician’s office and interfacing with the patient’s insurance carriers, (and other internal or external ancillary staff as appropriate), to make certain the patient has a determination for services rendered, with financial responsibility limited to payment of services as dictated by their respective Health Plan.
• Receives and documents written, telephonic, and electronic requests for referrals from Primary Care Physicians, Specialists and Ancillary providers.
• Contacts review organizations and insurance companies to ensure prior approval requirements are met. Verifies member eligibility and benefit coverage levels including obtaining information on coordination of benefits and third party liability as appropriate.
• Monitors the Referral Message Pool within the assigned POD
• Maintains a current working knowledge of all Health Plan carrier requirements for referral request authorizations and approval path requirements (Pre-Determinations and Peer to Peers).
• Creates agenda for and leads monthly POD meeting
• Completes research on referral inquires and/or referral issues. Provides feedback to Manager or Supervisor.
• Communicates workflow, policy, process and Health Plan changes to staff, within the assigned POD, as changes occur.
• Utilizes computer resources to determine provider networks.
• Upon request of Manager or Supervisor, audits completed referrals (within assigned POD), for accuracy and timeliness.
• Per referral guidelines, evaluates each referral request to ensure the referral request, including codes, place of service, service type, provider and all required medical information is available for submission to insurance carriers.
• Investigates and obtains missing medical information required for referral submission.
• Identifies and documents potential coordination of benefit and third party liability information when available.
• Monitors turn-around-times and work queues activity
• Applies knowledge and application of ICD-9 and CPT coding, as well as medical terminology for appropriate communication with physicians and providers.
• Orchestrates coverage, within the assigned POD, for staff that have scheduled time off and when unscheduled absences occur.
• Performs data entry/processing of referral requests through the EPIC system, and edits referral notes with appropriate information as outlines per department procedures.
• Ensures sources of referral and prior approval requests are provided with timely notification of approval or denial decisions through designated communication routes.
• Resources Supervisor or Manager for review of complex referral requests and issues.
• Works with Physician offices to provide ongoing education regarding referral process and requirements.
• Provides input to Supervisor and Manager regarding improvements to operating practices.
• Acts as a resource to staff members within the assigned POD.
• Provides training for new hires, within the assigned POD, and ongoing training as applicable. Communicates progress to Manager and Supervisor.
• Other duties as assigned

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED