The Referral Specialist focuses on the internal GMG referral processes, obtaining authorization from health plans and other UM entities for referrals, and communicating the outcome to patients, specialists, and other providers. This role seeks to enhance appropriate utilization by using GMG services and preferred providers for medically necessary care.
Duties
Run daily referral reports to create work list and monitor referrals in process.
Process referrals according to departmental goals, and accepted protocol, including referrals from internal GMG system, fax and mail from health plans, specialists, and other providers.
Verify insurance eligibility and benefits from HMO eligibility lists or by contacting insurance companies by phone when needed.
Enter referral information in the computer system using correct coding procedures; Document sufficient referral detail so it is clear what was requested, what occurred, what was approved, and who was notified.
Notify patients of the referral process, authorization decisions, and verify their understanding.
Notify referral provider of authorizations in a timely manner.
Conducts periodic review of previously authorized ongoing care for continued need and or eligibility.
Notify supervisor of problem referrals where turn around goals are exceeded or other issues are encountered.
Acts as liaison for Managed Care and PCP when patient has questions.
Serves as clinic information source regarding managed care and referrals
Demonstrate excellent customer service: Assist patients and staff to set up services or resolve concerns.
Keep PCP, clinical staff and Referral team members informed of pertinent findings/issues uncovered.
Document appropriately in GMG computer systems, and other associated systems.
Successfully meet production goals.
Able to work efficiently under pressure.
Maintain strict confidentiality.
Other duties as assigned.
Education and Experience: Minimum high school education or equivalent. Previous experience in managed care referrals. MA Certificate preferred. Some college business courses preferred. Must be able to use basic office equipment. Must have knowledge of ICD-9 and CPT-4 coding, medical terminology. Must have excellent customer service skills.
Computer Skills: Knowledge of Word Processing software, database software, spreadsheet and Internet software.
Supervisory Responsibilities: This job has no supervisory responsibilities.
Work Environment: Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinic environment.
Physical Demands: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.
The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Reasonable accommodations may be made to enable otherwise qualified individuals with disabilities to perform the essential functions of the job.
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Medical Practices
Referrals increase your chances of interviewing at Gonzaba Medical Group by 2x