Health Plan Referral Specialist - HP Utilization Management

Summary :

Processes all requests for referral authorizations and researches problem referral claims or requests for payment.

Responsibilities :

• Expedites the flow of authorization requests through the Managed Care System. Prepare requests for authorization of services by ensuring form completion, eligibility, verification, chart availability, benefits etc.
• Accurately enter referral information into the computer system with a thorough understanding of the correct system codes (type, status, procedure etc.)
• Facilitates documentation of authorizations into the computer system.
• Notifies patients and providers of authorization decisions and maintains accurate tracking of services.
• Request and print various system reports to perform daily tasks and to track referral based activity for management reporting purposes.
• Utilize tracking system to monitor the flow of referrals through the authorization process and to allow for measurement of turn around times and timely processing of referrals.
• Prepare requests for authorization of services by ensuring form completion, eligibility, verification, chart availability, benefits, etc.
• Notify all parties involved of authorization decisions to include patient, provider, requester, HMO, etc. Ensure appropriate actions have occurred such as scheduling of diagnostic appointments, requests for documentation / treatment plan etc.
• Distribute copies of referral to all appropriate sources (chart, provider, etc.) and accurately document activities associated with the referral in the medical file and computer system.
• Coordinate the initiation of specific home health services, DME services, diagnostics, etc., as directed by the nurse / physician for managed care plan members.
• Serve as a resource to staff and providers regarding managed care systems, HMO / PPO benefits, contracted providers, etc.
• Interface with HMO / PPO patients for direction through the referral process to increase an understanding of the authorization requirements mandated by the insurance plan.
• Promote and coordinate activities of payer agencies, groups or individuals to help provide answers and meet the needs of provider and / or patient.
• Assist in referral research for billing and collections process.
• Maintain contact with representatives of other organizations to exchange and update information on resources and services available.
• Demonstrate adherence to the CORE values of CHRISTUS.

Requirements :

Work Schedule :

8AM - 5PM Monday-Friday

Work Type : Full Time