Referrals Specialist

Job Description

Job Description

POSITION SUMMARY

Promotes timely and appropriate referrals for health care services by assisting clinical staff in the processing of prior authorization requests for ambulatory services and inpatient admissions.

COMPLIANCE WITH REGULATIONS :

Works closely with all departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and / or Medicare Part D, DHCS and DMHC.

RESPONSIBILITIES

• Maintains internal operations and compliance with established standards and timelines by receiving admission notifications and outpatient referral authorization requests via mail, fax, or telephone;
• determining member eligibility and reviewing plan benefits; entering appropriate CPT and / or ICD codes and referral / admission information in the Utilization / Case Management system;
• forwarding the request to assigned clinical staff for review, authorization and length of stay determination; following policies and procedures;

obtaining additional clinical documentation from a primary care provider or specialist, as requested by clinical staff; tracking and assisting claims re-routes, appeals, pending / denial letters, and CCS.

• Provides customer services to external / internal customers by assisting Community Health Group (CHG) contracted facilities, primary care provider sites, specialty and ancillary providers, and members and their families with information regarding access to health care services;
• utilizing clinical staff as a resource, reviewing plan benefits and prior authorization requirements with customers; educating health care providers regarding utilization management process;
• providing information about the special program and community services and transferring callers to other appropriate staff members as necessary;

producing and mailing hard copy responses, including non-certified and exhaustion of benefits letters, facility and members as applicable.

• Assists clinical staff by reporting medical care delivery issues to clinical supervisor; identifying potential over-or under-utilization of services, and gathering data obtained from daily referrals review to assist in reporting primary and specialty care practice patterns;
• reviewing appropriate coding of services and use of Community contracted providers; referring questionable referrals for clinical review;

assisting clinical staff with educating primary care providers.

Facilitates timely referral turnaround by receiving completed admission or referral requests from facility or clinical staff;

entering data and faxing or calling authorization / admission information to the appropriate provider.

• Ensures the provision of quality health care by monitoring, in conjunction with clinical staff, member and provider concerns;
• Potential Quality Issues (PQI), assisting in resolving problems involving access to appropriate levels of care; completing CQI forms and requesting reports;

maintaining confidentiality.

Contributes to the team effort by attending department meetings; giving and receiving feedback; accomplishing related results as needed;

assisting clinical staff in identifying areas requiring policies and procedures; working with clinical staff in policy development and periodic policy review.

Maintains filing system by maintaining accurate files of admissions and authorizations by facility / primary care site;

retrieving and / or reproducing files as needed; transferring and archiving documents per department protocols.

Maintains product and company reputation and contributes to the team effort by conveying a professional image and accomplishing related tasks;

participating on committees and in meetings; performing other duties as assigned or requested.

EDUCATION

• High school diploma or equivalent.
• Medical terminology.
• Associates degree in medical field preferred.

EXPERIENCE / SKILLS

• 2 years customer service and data entry experience in medical field.
• 3 years customer service and data entry experience in a managed care organization preferred.
• Ability to operate a personal computer, UM / CM System / HSD database, telephone, fax, and copier.
• Medical terminology including ICD-10 & CPT coding structures.
• Excellent customer service and communication skills.
• Detail-oriented.
• Bilingual (English / Spanish) preferred.

PHYSICAL REQUIREMENTS

• Prolonged sitting, data entry and telephone use.
• May be required to work evenings and / or weekends.

Must have current authorization to work in the USA

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws.

This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings.

Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity / Affirmative Action .

Company Description

Community Health Group (CHG) is a locally-based nonprofit health plan serving more than 360,000+ members in San Diego County.

For 38 years CHG has been dedicated to coordinating quality care and providing exceptional customer service. Our more than 300 committed and well-trained employees do this as stewards of government funds from health-related programs (Medi-Cal and Cal MediConnect) designed to protect the most vulnerable people in our society.

Providing access to culturally sensitive, quality care for our members is at the heart of what we do each and every day.

Company Description

Community Health Group (CHG) is a locally-based nonprofit health plan serving more than 360,000+ members in San Diego County.

For 38 years CHG has been dedicated to coordinating quality care and providing exceptional customer service. Our more than 300 committed and well-trained employees do this as stewards of government funds from health-related programs (Medi-Cal and Cal MediConnect) designed to protect the most vulnerable people in our society.

Providing access to culturally sensitive, quality care for our members is at the heart of what we do each and every day.