Due to our rapid growth, we have several positions available for remote/on-site positions in the following states (FL, GA, MD, PA, PR, TN and TX). This position is responsible for servicing the needs of patients by receiving phone calls from both members and referrals from providers to facilitate the authorization and coordination of referrals utilizing pre-approved screening criteria in compliance with contracted Client's requirements.
Essential Functions & Responsibilities
- Receives phone calls and faxed referral requests from providers.
- Verifies member eligibility and benefits.
- Inputs all referral requests including ICD-10 and CPT codes into system accurately for electronically generated authorization tracking.
- Provides referral authorization to external providers per UM Departmental Policy and Procedures and specific contracted Client's process.
- Requests submission of appropriate medical records according to established criteria for requested service(s).
- Issues authorization within appropriate timeframe for routine, urgent and emergent requests.
- Appropriately forwards all referral requests to the next level of review.
- Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.
- Coordinates approved services with Home Health Providers, Plan discharge Planners and Plan Members as delegated or required by Plan.
- Is resource person for PCP to refer to network specialist(s).
- Compiles monthly departmental statistics.
- Distributes correspondence and other information to the appropriate parties or departments.
- Maintains appropriate logs, records, and reports as established by Utilization Department.
- Documents and communicates areas of concern to supervisor.
- Identifies providers who are problematic with plan requirements.
- Adheres to company HIPAA policies and procedures.
- Ensures integrity of data entry is accurate.
- Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
- Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
- Ability to come to work and work the regular schedule and shift for the position.
- Compliance with all personnel policies and procedures.
- Perform additional duties and related essential duties as assigned.
Required Education and Experience
- High school diploma or general education degree (GED); or one to three months related experience and/or training;
- or equivalent combination of education and experience.