Coordinator Referrals - Pedi Cardiology

Summary:

This position is responsible for coordinating the entire referral process (obtaining order from physician, obtaining insurance authorization from the insurance company/payor, scheduling the appointment for the patient with a physician who accept the particular insurance, notifying the patient of the appointment, completing renewal authorizations with physicians office and payor) for a 35 physician practice. Researches problem referral claims or requests for payment and corrects. Ensures physicians coding and Dx are appropriate for proper referral and coverage by insurance company. This position is also responsible for knowing various insurance plans and coverages for the patient to ensure proper payment. Responsible to teach nursing associates and physicians all changes within insurance plans for referral and authorization process. Must be up to date with all CPT and ICD-9 coding to process proper referral. Must have clinical background knowledge to appropriately support referral when communicating with insurance companies.

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) as well as, CPT codes and ICD-9 codes that will support the referral.
• Coordinates the Non-Subscriber Workman's Compensation for CHRISTUS Santa Rosa and the Corporate Office to ensure proper authorization for the associates care and proper payment occurs to the Family Health Center.
• Facilitates documentation of authorizations into the computer system.
• Notifies patients and providers of authorization decisions and maintains accurate tracking of services.
• Responsible to teach nursing associates and physicians all changes within insurance plans for referral and authorization process.
• 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 patients EMR.
• 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.
• Provides all necessary information (medical records, scripts, etc) to payer and refer to provider as needed for continuity of medical care
• 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.
• Experience with billing and collections for physician office practice required
• Maintains compliance at all times with federal regulations such as "Anti-kickback, etc."
• Follows AIDET at all times.
• Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department.
• Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served.
• Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.
• Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.
• Demonstrates adherence to the CORE values of Santa Rosa Health Care.
• Performs other duties as assigned.

Requirements:

Education:

• High School Diploma or equivalent is required.

Experience:

• Minimum 3 years office experience in a healthcare setting required.
• Expert knowledge of managed care benefit plans with at least 1 year specializing in a referral-based clinic or physician's office.

Licensure/Certification:

• Medical assistant certification from an approved technical school preferred.

Equipment/Skills:

• Must have excellent customer service skills, communicating with all customers (physicians, patients, insurance companies, staff etc.
• Bilingual (English and Spanish) is preferred.
• Must be able to deal with stress and handle difficult patients with tact and courtesy.
• Must be computer literate.
• Experience with billing and collections for physician office practice required.
• Must have a minimum score of 60 gross data sets per hour, 6000 keystrokes per hour and 2% or less error rate on a standard data entry test.
• Must understand importance of patient confidentiality, and adhere to confidentiality expectations at all times.
• Must be able to work independently, with little or no direct supervision. Must be able to follow instructions accurately.

Working Conditions/Physical Requirements:

• Works in an office setting with adequate lighting and climate control.
• Work requires periods of time working with computer.
• Must successfully complete the pre-employment/post job offer health screening examination and the annual screening each year thereafter as an employee.
• Work may require flexible and/or extended hours, in order to meet customer needs.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time