Referral Specialist

2 days ago

South Bend, United States Beacon Health System Full time
  • Reports to the Manager and works under the direction of the Centralized Office Supervisor under general supervision and according to established policies and procedures. Responsibilities include scheduling specialty and/or diagnostic procedures to ensure the customer's next step(s) in care are well coordinated within Beacon Health System whenever possible. Communicating with empathy and clarity regarding the details of the next step in care for the customer. Obtains prior authorizations as necessary to ensure reimbursement occurs at the highest possible level to assist in prevention of prior authorization denials.
MISSION, VALUES and SERVICE GOALS
  • MISSION: We deliver outstanding care, inspire health, and connect with heart.
  • VALUES: Trust. Respect. Integrity. Compassion.
  • SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Referral Specialist/Integrated Care duties in accordance with established policies and procedures by:
    • Coordinating care that is customer centric; timely, convenient and coordinated.
    • Using knowledge of CPT codes and ICD-10 to ensure exam meets medical necessity and procedural guidelines.
    • Ensuring referrals are scheduled using knowledge of insurance network guidelines, in accordance with the customer's insurance rules and Regulations.
    • Communicating with the provider in a collaborative and confident manner.
    • Ensuring proper testing is done utilizing tools in accordance with the provider's desire and the testing criteria and guidelines including both insurance and modality ordering guidelines
    • Recognizing issues using critical thinking skills to prevent denials.
    • Coordinating care within the Beacon Health System by using identified best practice tools and resources to their highest potential.
    • Scheduling all testing (Outpatient Diagnostic and Specialty) appointments in a manner that is customer centric.
    • Interpreting physician's instructions and communicates instructions in a clear manner and can adjust communication style to meet the needs of the customer when necessary.
    • Assisting management team to identify referral patterns by inputting referral data into the referral database in a detailed, thorough manner.
    • Using critical thinking skills to identify problems, create solutions and helping to implement the change.
    • Prioritizing work in an effective manner.
    • Working at a fast pace and maintaining accuracy.
    • Maintaining up-to-date knowledge and stays abreast of changes and updates as they occur. (Includes but not limited to, Insurance, Referral Database, Department and Processes changes.
    • Advocating for the customer by displaying the ability to recognize when to dispute a non-desirable outcome regarding PA approval (prior authorization).
    • Disputing and negotiating when necessary on behalf of BHS and the customer for a positive prior authorization outcome.
    • Understanding the flow and rhythm of each task and can connect each resulting convenient, connected and coordinated care.
    • Using numerous software platforms (multiple EMR's, insurance websites, referral database, scheduling software, etc.) to conduct tasks for patient care.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
    • Assisting others and/or accept additional duties.
    • Enhancing professional growth and development through in-service meetings and educational programs as approved.
ORGANIZATIONAL RESPONSIBILITIES
  • Associate complies with the following organizational requirements:
    • Attends and participates in department meetings and is accountable for all information shared.
    • Completes mandatory education, annual competencies and department specific education within established timeframes.
    • Completes annual employee health requirements within established timeframes.
    • Maintains license/certification, registration in good standing throughout fiscal year.
    • Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
    • Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
    • Adheres to regulatory agency requirements, survey process and compliance.
    • Complies with established organization and department policies.
    • Available to work overtime in addition to working additional or other shifts and schedules when required.
  • Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
    • Leverage innovation everywhere.
    • Cultivate human talent.
    • Embrace performance improvement.
    • Build greatness through accountability.
    • Use information to improve and advance.
    • Communicate clearly and continuously.
Education and Experience
  • The knowledge, skills and abilities as indicated are normally acquired through the successful completion of a high school diploma or equivalent; successful completion of an approved Medical Assistant Program with successful completion of the Certification Exam or equivalent medical office experience. Medical terminology, ICD-10, CPT, / prior authorizations, and specialty/diagnostic referral experience required.
Knowledge & Skills
  • Demonstrates well developed communication skills to communicate effectively and clearly to a variety of internal and external contacts.
  • Demonstrates analytical skills necessary to solve problems and interpret data.
  • Promotes collaboration and innovation in the clinical services to ensure an interdisciplinary approach to improving healthcare delivery and the quality of patient care.
  • Must be tactful in handling patient problems often of a highly personal and confidential nature.
  • Must be able to maintain professionalism during potential frustrating interpersonal situations.
  • Demonstrates a high knowledge level of procedures; including knowledge of CPT codes and ICD-10 Codes.
  • Demonstrates a working knowledge (referrals) high knowledge (prior authorization) of insurance network guidelines to ensure the referral is scheduled in accordance with customer's insurances rules and regulations
Working Conditions
  • Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needed.
  • May need to travel to other Beacon locations.
  • Working space is frequently congested by other personnel.
  • Constantly exposed to noise and distraction.
Physical Demands
  • Requires the physical ability and stamina to perform the essential functions of the position.
  • Sitting for long periods of time in front of a computer monitor.

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