Preferred prior knowledge of the below systems/websites:

Evicore

Carelon

UHC

RadMD

Availity

HealthHelp

Meridian Portal

Cohere

Major Responsibilities:

• Management and navigation of the centralized referral process.
  • 8)Logs member or physician complaints related to ancillary vendors as well as investigates and documents follow-up of complaints.
  • 1)Works in all aspects of centralized referral process, including processing referrals to members, physicians and specialists, under the direction of the supervisor, RNs and Medical Directors and per medical policies and criteria.
  • 2)Generates necessary correspondence or calls to members, physicians and office staff, managed care organizations or vendors requesting additional information.
  • 3)Communicates with appropriate staff and members regarding follow-up status of referrals.
  • 4)Works with UM staff to file, prepare correspondence, data entry, system documentation and other medical management related activities.
  • 5)Reconciles and investigates the daily pended claims report to ensure the proper payment of claims in a timely manner and utilizes the pended claims report to recognize areas of opportunity to provide outreach to members in an attempt to bring them back into the Advocate network.
  • 6)Coordinates the initial referral and renewal of home care, DME and disposable supplies under the supervision of RN for the outpatient population.
  • 7)Evaluates the cost-effectiveness of DME purchase versus rental.
• Responsible for the coordination and monitoring of discharge planning to provide cost effective care and quality outcomes to members in accordance with their benefit coverage guidelines.
  • 1)Works with the Hospital Care Manager to coordinate discharge planning referral needs when indicated.
  • 2)Provides authorization of contracted vendors for home health, DME, Skilled Nursing Facilities, and ambulance referrals.
  • 3)Generates referral authorization for in network specialists as well as diagnostic and imaging requests as defined by the network.
  • 4)Documents in IDX the appropriate referral information in a timely fashion to ensure that claims are processed appropriately and to meet the requirements established for compliance by the payers and CMS.
  • 5)Is responsible for being available telephonically in order to provider referral authorization in a timely fashion to the Hospital Care Manager.
• Participate in education and utilization management activities
  • 3)Verify eligibility for members including coordination of benefits and third party liability, benefit coverage levels, and problem resolution with Advocate MSO and various managed care organizations.
  • 4)Identifies and maintains appropriate communication with Supervisor regarding problems and observations in the course of daily operations.
  • 1)Acts as a resource in the education of physician office staff on referral procedures, AHP policies and procedures, and benefit plan limitations as well as a resource to customers and assists in the resolution of referral, claim, and eligibility issues.
  • 2)Communicates with the AMG Case Manager, Supervisor, Manager, Director, other health care professionals, and various staff in a positive fashion in order to promote member satisfaction, quality services delivered, and resolution of issues.

Education/Experience Required:

• AA Degree or equivalent 3-4 years experience in a managed care organization, hospital or physician's office. Medical record experience preferred and/or medical terminology

Knowledge, Skills & Abilities Required:

• Good verbal and written communications skills. Excellent interpersonal communication skills. Ability to work as a team member. Good computer keyboard proficiency. Good organizational skills. Ability to handle difficult calls and maintain professional conduct. Willingness to be flexible with job responsibilities
• Certified Medical Assistant preferred. MRT preferred.

Physicial Requirements and Working Conditions:

• Ability to work under stressful conditions. Ability to handle stress and high workload volumes. Flexible with work assignments. Ability to communicate denial of services to members and providers Ability and willingness to be cross-trained in all referral specialist activities.
• If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.