Creates and assists with the preparation of referral requests. As part of the preparation process will verify eligibility, benefits, request any needed clinical notes and accurately complete or forward referral to appropriate staff to finalize decision. Ensures that all referral policies and procedures are followed as required to meet all contractual, regulatory and federal requirements
Essential Job Outcomes
Eligibility and benefits verification via website or telephone. Accurately and clearly documents information within the referral.
Assist in verifying accuracy of member address prior to completing the authorization.
Assure authorizations and member verbal notifications on urgent determinations are completed to meet current regulatory requirements as well as any additional required written notification requirements.
Consistently follow department processes for the following: Referral authorization- inpatient, outpatient, Urgent, Emergent, Routine referrals and FFS as assigned.
Run daily reports to capture all incoming referrals from the Portal, Electronic Medical Record, PCP, Specialists and account for Emergent/Urgent, ASA (auto status approval) referral and/or ODAG reports and other requested ad hoc reports for utilization, productivity and operational metrics.
Demonstrate the ability to explain managed care principles to others, i.e. contracted, non-contracted, full risk, shared risk, in-network, out-of-network, etc.
Correct authorizations that were incorrectly entered into the referral system.
Maintain 100% compliance in patient/employee confidentiality, as well as HIPAA compliance.
Request any clinical notes needed for reviewers.
Attach pertinent clinical criteria when needed and ensure documents are accurately labeled in referral system
Ensure scanned faxes and clinical notes are attached to the correct referral.
Demonstrates the ability to competently utilize the computer system and software for processing referrals
Demonstrate knowledge of Medical Terminology in order to respond to inquiries and be able to accurately translate and communicate complex information from the Health Plans, Case Management Nurses, Patients, Staff and vendors.
Answer telephone inquiries from physicians, staff and patients accurately and timely
Accurately approve referrals that fall within their scope of practice as determined by the medical management department.
Serve as resource for other departments, i.e. claims, network, customer service
Perform other duties as assigned by Management team
Experience in Managed Care or Medical Field 1-2 years preferred. Familiarity with the interpretation of health plan benefit manuals and CPT/ICD coding, preferred.
Type with speed and accuracy, 40 - 50 wpm.
Must have excellent computer skills.
Excellent customer service skills and be a team player.
Must be dependable.
High degree of organizational skills.
Must be a High School Graduate/ or G.E.D or equivalent.
Medical terminology, preferred.
Internal Number: MEM003648
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.