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Health Plan Referral Specialist – Health Plan Admin
Summary:
This position is responsible for the coordination of Referral/Precertification Management information between the UM/CM Department and providers via telephone, email and/or faxed clinical information. This position also performs selected data entry as submitted by medical providers.
Responsibilities:
• Receive, process and complete data entry of demographic information for all referral and authorization requests from providers via fax or phone and as appropriate, forward to precertification nurse/care manager/case manager.
• Begin on-line process utilizing skills of typing, medical terminology, and ICD/CPT coding.
• Request, document and forward out of network provider demographic information to PR Department and update case when appropriate
• Using internal scripts, process requests per department procedures
• Begin on-line process of above, utilizing skills of typing, medical terminology, and ICD/CPT coding
• Coordinate daily review activity for on-site utilization nurses
• Data entry of designated referrals/authorizations per management directive
• Assist in maintaining files for department
• Scan electronically attach notes and notify appropriate staff for follow up
• Adhere to AAAHC, NCQA and other regulatory standards
• Communication, Collaboration and Coordination with all customers, internal and external
• Collaborate with and maintain open communication with all other departments as appropriate and required to facilitate completion of tasks/goals
• Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI)
• Attend monthly departmental meetings and/or interdepartmental meetings as appropriate
• Ability to sit for long periods of time.
• Ability to organize and prioritize work to meet deadlines.
• Ability to work occasional long or irregular hours.
• Good speaking ability, judgment, and initiative Ability to work a flexible work schedule including evenings and weekends
Requirements:
• High school diploma
• Working Knowledge of Medical terminology and CPT background
• Good typing skills
• Basic knowledge of computers
• Excellent customer service skills
• Works well with diverse groups of individuals
• Minimum of two years in related working environment such as hospital, physician office, or managed care organization
Work Type:
Full Time
EEO is the law – click below for more information:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf
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