Referral Specialist

Department:

Status:

Benefits Eligible:

Hours Per Week:

Schedule Details/Additional Information:

Monday-Friday, no weekends

Rotating weekly shifts:

• Week 1: 8:00 AM – 4:30 PM
• Week 2: 8:30 AM – 5:00 PM

Familiarity with the following systems is highly desirable:

• Evicore
• Carelon
• UnitedHealthcare (UHC)
• RadMD
• Availity
• HealthHelp
• Meridian Portal
• Cohere

Pay Range

• Management and navigation of the centralized referral process.
  •     Logs member or physician complaints related to ancillary vendors as well as investigates and documents follow-up of complaints.
  •     Works in all aspects of centralized referral process, including processing referrals to members, physicians and specialists, under the direction of the supervisor, RNs and Medical Directors and per medical policies and criteria.
  •     Generates necessary correspondence or calls to members, physicians and office staff, managed care organizations or vendors requesting additional information.
  •     Communicates with appropriate staff and members regarding follow-up status of referrals.
  •     Works with UM staff to file, prepare correspondence, data entry, system documentation and other medical management related activities.
  •    Reconciles and investigates the daily pended claims report to ensure the proper payment of claims in a timely manner and utilizes the pended claims report to recognize areas of opportunity to provide outreach to members in an attempt to bring them back into the Advocate network.
  •    Coordinates the initial referral and renewal of home care, DME and disposable supplies under the supervision of RN for the outpatient population.
  •    Evaluates the cost-effectiveness of DME purchase versus rental.
• Responsible for the coordination and monitoring of discharge planning to provide cost effective care and quality outcomes to members in accordance with their benefit coverage guidelines.
  •     Works with the Hospital Care Manager to coordinate discharge planning referral needs when indicated.
  •     Provides authorization of contracted vendors for home health, DME, Skilled Nursing Facilities, and ambulance referrals.
  •     Generates referral authorization for in network specialists as well as diagnostic and imaging requests as defined by the network.
  •     Documents in IDX the appropriate referral information in a timely fashion to ensure that claims are processed appropriately and to meet the requirements established for compliance by the payers and CMS.
  •     Is responsible for being available telephonically in order to provider referral authorization in a timely fashion to the Hospital Care Manager.
• Participate in education and utilization management activities
  •     Verify eligibility for members including coordination of benefits and third-party liability, benefit coverage levels, and problem resolution with Advocate MSO and various managed care organizations.
  •    Identifies and maintains appropriate communication with Supervisor regarding problems and observations in the course of daily operations.
  •     Acts as a resource in the education of physician office staff on referral procedures, AHP policies and procedures, and benefit plan limitations as well as a resource to customers and assists in the resolution of referral, claim, and eligibility issues.
  •     Communicates with the AMG Case Manager, Supervisor, Manager, Director, other health care professionals, and various staff in a positive fashion in order to promote member satisfaction, quality services delivered, and resolution of issues.

Education/Experience Required:

• AA Degree or equivalent 3-4 years' experience in a managed care organization, hospital or physician's office. Medical record experience preferred and/or medical terminology

Knowledge, Skills & Abilities Required:

• Good verbal and written communications skills. Excellent interpersonal communication skills. Ability to work as a team member. Good computer keyboard proficiency. Good organizational skills. Ability to handle difficult calls and maintain professional conduct. Willingness to be flexible with job responsibilities
• Certified Medical Assistant preferred. MRT preferred.

Physicial Requirements and Working Conditions:

• Ability to work under stressful conditions. Ability to handle stress and high workload volumes. Flexible with work assignments. Ability to communicate denial of services to members and providers Ability and willingness to be cross-trained in all referral specialist activities.
• If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

About Advocate Health 

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation's largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.