Referral Specialist

JOB SUMMARY

This position is responsible for the verification/authorization of patient care services to ensure financial reimbursement.  Responsible for insurance benefit verification and provision of clinical information for insurance plans that require a referral order and authorization/pre-certification for specialty services, surgeries and other procedures and services as required by insurance companies.  Interpret medical record documentation for patient history, diagnosis, and treatment options to facilitate authorizations.  Communicates effectively and professionally with many stakeholders. Complete necessary forms for insurance companies and initiates appropriate follow-up.  Process patient referrals to other specialties, both within Mercyhealth and to outside providers, if necessary.  Process appeals and denials related to the referrals process. Utilizes excellent customer service by demonstrating written and oral communication skills.  Documents thoroughly and according to department and health system guidelines and expectations. Performs additional duties as assigned.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Identifies patients requiring referral authorizations/precertification for specialty services, surgeries, and other medical procedures as required by insurance.
Contact insurance companies or employer groups to determine eligibility and benefits for necessary services.
Contact clinical offices and/or Primary Care Physicians for issues related to incomplete or invalid referrals.
Make necessary contact to follow up if there are insurance issues to ensure financial resolution and payment on accounts.
Obtain required clinical documentation to be used in authorization process.
Ensure timely documentation and communication of referral authorization/precertification in appropriate systems.
Ensures patients have been cleared for specialty service office visits.
Resolves pre-certification, registration and case-related concerns prior to a patient’s appointment.
Coordinate follow up to ensure all payor requirements are met and payment is expected.
Obtain patient insurance information as needed to meet payor requirements.
Maintains current knowledge of payor payment provisions and regulations.
Keeps abreast of denials related to referrals and assist with appeals as needed.
Keep current of CPT and other coding requirements
Participate in educational programs to meet mandatory requirements of position.

CULTURE OF EXCELLENCE BEHAVIOR EXPECTATIONS

To perform the job successfully, an individual should demonstrate the following behavior expectations:

Quality – Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.

Service – Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.

Partnering – Shows commitment to the  Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other’s views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.

Cost – Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

EDUCATION & EXPERIENCE

High school diploma or equivalent required.

One year of healthcare registration, scheduling, or physicians’ office experience required. Completion of 24 (twenty four) hours of coursework in a business or healthcare related field of study may be considered in lieu of healthcare office experience.

Knowledge of third party payor requirements

Basic knowledge of medical terminology

Basic knowledge of ICD-9, ICD-10, and CPT coding preferred

Excellent customer service and telephone etiquette

ADDITIONAL REQUIREMENTS

Passing the Driver’s License Check and/or Credit Check (for those positions requiring).

Passing the WI Caregiver Background Check and/or IL Health Care Workers Background Check.

Must be able to follow written/oral instructions.

OTHER SKILLS AND ABILITIES

Medical Terminology, CPT, ICD-10 experience preferred.

Awareness of health care industry business trends and developments including, but not limited to, Health Care Reform.

Must be proficient with Microsoft Office Suite, including Outlook, Excel and Word. Must have sufficient computer skills to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, and electronically notate registration software, and other required applications/systems.

Demonstrated ability to communicate clearly and concisely, both verbally and in writing, with peers, supervisors, payers, physicians, patients, other departments.

Excellent oral communication skills/organizational skills

Ability to handle stress and problem solve

Computer experience required

Knowledge of Epic desirable

Able to work independently

WORK ENVIRONMENT

The noise level in the work environment is usually quiet.

Occupational Exposure: Category C – No partners in the specified job classification have occupational exposure.

AGE OF PATIENTS SERVED

Neonate (birth – 28 days)

Infant (29 days – less than 1 year)

Pediatric (1 year – 12 years)

Adolescents (13 years – 17 years)

Adult (18 years – 64 years)

Geriatric (65 years and older)

INFORMATION ACCESS

Partner may access patient care and financial information needed to perform their job duties.