Referrals Specialist

3 months ago

Chula Vista, United States Community Health Group Full time
Job DescriptionJob 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 DescriptionCommunity 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 DescriptionCommunity 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.

  • Bilingual Referral Coordinator

    1 week ago

    Chula Vista, California, United States TrueCare Full time

    Job SummaryWe are seeking a highly skilled and detail-oriented Medical Referral Specialist to join our team at TrueCare. As a Medical Referral Specialist, you will be responsible for coordinating and processing medical referrals for services and procedures requested by medical providers.Key ResponsibilitiesCoordinate and process medical referrals for...

  • Bilingual Referral Coordinator

    2 days ago

    Chula Vista, California, United States TrueCare Full time

    Job SummaryWe are seeking a highly skilled and detail-oriented Medical Referral Specialist to join our team at TrueCare. As a key member of our Referrals Department, you will be responsible for coordinating, processing, and obtaining prior authorizations for medical referrals.Key ResponsibilitiesCoordinate and process medical referrals for services and...

  • Bilingual Patient Referral Specialist

    2 weeks ago

    Vista, United States TrueCare Full time

    Position Overview:TrueCare is seeking a dedicated and detail-oriented professional for the role of Bilingual Referral Coordinator. This temporary position offers a competitive hourly wage ranging from $21.50 to $26.88.Role Responsibilities:The Referral Coordinator will be tasked with the essential duties of coordinating, processing, and obtaining prior...

  • Bilingual Patient Referral Specialist

    2 weeks ago

    Vista, United States TrueCare Full time

    Position Overview:TrueCare is seeking a dedicated and detail-oriented professional for the role of Temporary Referral Coordinator. This position is essential in ensuring that patients receive the necessary care they require through effective coordination of medical referrals.Key Responsibilities:Coordinate and process medical referrals for various services...

  • Bilingual Patient Referral Specialist

    2 weeks ago

    Vista, United States TrueCare Full time

    Position Overview:TrueCare is seeking a dedicated and detail-oriented professional for the role of Temporary Referral Coordinator. This position plays a crucial role in ensuring that patients receive the necessary medical services and support they require.Key Responsibilities:Coordinate and process medical referrals for various services and procedures as...

  • Bilingual Patient Referral Specialist

    2 weeks ago

    Vista, United States TrueCare Full time

    Position Overview:TrueCare is seeking a dedicated and detail-oriented professional for the role of Bilingual Referral Coordinator. This temporary position offers a competitive hourly wage ranging from $21.50 to $26.88.Key Responsibilities:Coordinate and process medical referrals for various services and procedures as directed by healthcare providers.Obtain...

  • Bilingual Patient Referral Specialist

    2 weeks ago

    Vista, United States TrueCare Full time

    Position Overview:TrueCare is seeking a dedicated and detail-oriented professional for the role of Temporary Referral Coordinator. This position is essential in ensuring that patients receive the appropriate care and services they require.Key Responsibilities:Coordinate and process medical referrals for various services and procedures as requested by...

  • Bilingual Patient Referral Specialist

    2 weeks ago

    Vista, United States TrueCare Full time

    Position Overview:TrueCare is seeking a dedicated and detail-oriented professional for the role of Temporary Referral Coordinator. This position is integral to our mission of delivering comprehensive and quality healthcare to all individuals, regardless of their financial situation.Key Responsibilities:Coordinate and process medical referrals for various...

  • Client Relations Specialist

    1 week ago

    Chula Vista, California, United States Lendmark Financial Services Full time

    Position Overview: Client Relations SpecialistThe Client Relations Specialist role is dedicated to delivering outstanding service to clients while identifying tailored financing options. This position is essential in fostering a loyal clientele through effective sales strategies, loan renewals, and customer referrals. Success in this position hinges on the...

  • Vocational Nursing Specialist

    2 weeks ago

    Chula Vista, California, United States Healthcare Staffing Professionals, Inc Full time

    Healthcare Staffing Professionals, Inc. - Vocational Nursing Specialist RoleHealthcare Staffing Professionals, Inc. is on the lookout for skilled Vocational Nurses for a temporary assignment at a specialized clinic.Key Responsibilities:Deliver nursing care within a clinical environmentSupport patient evaluations and treatment proceduresCompensation: $40 per...

  • Referral Coordinator

    7 days ago

    Vista, California, United States Vista Community Clinic Full time

    Job SummaryVista Community Clinic is seeking a highly organized and detail-oriented Referral Coordinator to join our team. As a Referral Coordinator, you will play a critical role in ensuring seamless communication between our clinicians and external healthcare providers.Key ResponsibilitiesReferral Coordination: Coordinate, process, and obtain prior...

  • Metal Fabrication Specialist

    2 weeks ago

    Chula Vista, California, United States Ameri-Force Full time

    Job OverviewPosition Summary: The Metal Fabrication Specialist is tasked with the creation, assembly, and installation of various components for naval vessel repairs and other marine and commercial applications. The components include, but are not limited to, ventilation systems, metal partitions, structural framing, furniture, cabinetry, lockers, ladders,...

  • Personal Banker and Sales Specialist

    1 month ago

    Chula Vista, United States FirstBank Full time

    Position Details Banking Specialist III - Sales Focus This position, Banking Specialist III, may be called by many other names: New Accounts Representative, Personal Banker, Financial Service Representative, etc. At First Bank, we choose to call you a "specialist" because that is what you are! Individuals in this position are well-versed in both operations...

  • Kitchen Preparation Specialist

    2 weeks ago

    Chula Vista, California, United States Black Angus Steakhouse LLC Full time

    Job OverviewWe are seeking dedicated KITCHEN PREPARATION SPECIALISTS who are committed to delivering an Exceptional Experience for our Guests by assisting in the culinary preparation of dishes in our kitchen.Key Responsibilities: * Interpret and execute recipes accurately * Prepare ingredients by washing, chopping, and organizing * Execute routine food...

  • Retail Sales Specialist

    2 days ago

    Chula Vista, California, United States Advantage Sales and Marketing, LLC Full time

    About UsAdvantage Sales and Marketing, LLC is a leading provider of sales and marketing solutions to the retail industry. We are committed to helping our clients connect with their customers and drive sales growth.Job SummaryWe are seeking a highly motivated and experienced Retail Sales Specialist to join our team. As a Retail Sales Specialist, you will be...

  • Pet Care Specialist

    5 days ago

    Chula Vista, California, United States BeLoved Pet Sitting Full time

    Job Opportunity at BeLoved Pet SittingAbout Us:BeLoved Pet Sitting is a reputable pet care provider in San Diego, dedicated to delivering exceptional services to our clients and their beloved pets.Job Summary:We are seeking a reliable and compassionate Pet Care Specialist to join our team. As a Pet Sitter, you will be responsible for providing top-notch care...

  • Safety Associate

    6 days ago

    Chula Vista, California, United States South Bay Community Services Chula Vista Full time

    About the RoleSouth Bay Community Services Chula Vista is seeking a highly motivated and detail-oriented individual to fill the position of Safety Associate - Crisis Response Specialist. This role is a critical part of our team, responsible for maintaining and overseeing the safety and security of our facility and clients.Key ResponsibilitiesProvide a...

  • Diagnostic Imaging Specialist and Medical Support Professional

    6 days ago

    Chula Vista, California, United States Concentra Full time

    About the RoleWe are seeking a highly skilled Radiologic Technologist and Medical Support Specialist to join our team at Concentra. As a key member of our healthcare team, you will be responsible for performing routine x-ray examinations and providing exceptional patient care in a fast-paced environment.Key ResponsibilitiesPrepare patients for radiologic...

  • Developmental Specialist II

    1 week ago

    Chula Vista, United States Family Health Centers of San Diego Full time

    Impact Lives, Impact CommunityFamily Health Centers of San Diego (FHCSD) is passionate about providing exceptional health care to all, especially underserved communities with limited health care options. Founded by a Latina grandmother/community advocate over 50 years ago in Barrio Logan, FHCSD has grown into one of the largest community health systems in...

  • Retail Sales and Inventory Specialist

    2 weeks ago

    Chula Vista, California, United States The Salvation Army USA Western Territory Full time

    COMPENSATION:$16.00 per hourABOUT THE ORGANIZATIONThe Salvation Army (TSA) Adult Rehabilitation Center (ARC) offers a no-cost program designed to support individuals in their journey towards completing our rehabilitation services. We deeply appreciate the contributions made by our dedicated employees, which are vital to the success and efficiency of our...