Lead Referral Specialist

TriWest Healthcare Alliance Corp.; Phoenix (AZ); Remote; USD 51,000 - 54,000; Full time

Benefits offered by this job

Medical, Dental and Vision Coverage

401(k) Retirement Savings Plan (with-m

Paid time off

Job summary

TriWest Healthcare Alliance seeks a detail-oriented Authorization Support Specialist to ensure accurate data entry and timely processing of TRICARE referrals. You will handle complex documentation from military facilities, maintain HIPAA standards, and provide guidance to junior staff in a fast-paced setting.

The role supports multiple teams, can operate in a virtual environment, and requires at least one year of TRICARE processing experience, strong Microsoft Office skills, and a commitment to

Qualifications

• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• High School Diploma or GED
• At least one year TRICARE referral and authorization processing experience
• Demonstrated proficiency with specialty processes
• Experience with Microsoft Office

Responsibilities

• Provides support to data entry and specialty teams with questions and issues. Performs referral processing as needed.
• Acts as a Point of Contact as needed for MTF or Field Support staff.
• Provides education as needed to referral specialist level one and level two staff.
• Assesses tasks for authorization/referral request to ensure accurate entry into the medical management system.
• Identifies potential discrepancies in the medical management system to assure quality compliance.
• Consistently meet department productivity and performance metrics.
• Follow HIPAA compliance and TriWest confidentially guidelines.
• Refers beneficiaries to network providers.
• Resolves issues to complete care request.
• Reads and comprehends diagnosis, procedures and requested service on incoming care requests. Assists in producing trend reports to improve workflow efficiency and system functions to recommend possible solutions to management.
• Assists with resolving data quality issues by identifying, documenting, and communicating quality issues.
• Resolve process issues to ensure high quality service levels throughout TriWest. Seeks advice and escalates issues or problems as warranted.
• Processes referrals for Behavioral Health, Specialty Care, Durable Medical Equipment, Inpatient Admissions, Military Treatment Facilities, and Urgent referral and authorization requests.
• Assesses electronic documents to ensure appropriate entry into the medical management system.
• Works with standard coding systems including: standard medical taxonomy, ICD-10, CPT and HCPCS codes.
• Verifies beneficiary eligibility and ensures appropriate referral procedures are followed for the various types of TRICARE beneficiaries.
• Ensures procedures are followed for referrals based on beneficiary eligibility type, geographical location, and on the provider's request.
• Processes authorization requests and referral requests in the on-line medical management system.
• Initiates the Knowledge Skills and Abilities process for the referrals, to ensure appropriate care is being requested at Military Treatment Facilities.
• Communicates with other departments, medical providers, and beneficiaries to clarify documentation prior to processing.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Skills

Communication / People Skills

Coping / Flexibility

Empathy / Customer Service

Multi-Tasking / Time Management

Organizational Skills

Problem Solving / Analysis

Technical Skills

Education

High School Diploma or GED

Tools

Microsoft Office

Job description

Profile

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen, and military family members are encouraged to apply!

Job Summary

Provides subject matter expert support to assigned team. Ensures accuracy and completion of authorization data from customer information, medical records, referral/authorization forms, Military Treatment Facility electronic transmission and other documents into medical management system. Examine and evaluate document contents to ensure accuracy and to correct inconsistencies. Prioritizes referral/authorization submissions and forwards documents to appropriate parties for handling and processing requests. Duties may be performed in a virtual environment. Maintains confidentiality of TriWest beneficiaries' health information.

Education & Experience

Required

• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• High School Diploma or G.E.D.
• At least one year TRICARE referral and authorization processing experience
• Demonstrated proficiency with specialty processes
• Experience with Microsoft Office

Preferred

• Knowledge of medical terminology obtained through medical assistant certification or experience interpreting and applying ICD and CPT codes
• Team Lead experience
• Managed Care experience
• Veteran or military spouse or military affiliated

Key Responsibilities

• Provides support to data entry and specialty teams with questions and issues. Performs referral processing as needed.
• Acts as a Point of Contact as needed for MTF or Field Support staff.
• Provides education as needed to referral specialist level one and level two staff.
• Assesses tasks for authorization/referral request to ensure accurate entry into the medical management system.
• Identifies potential discrepancies in the medical management system to assure quality compliance.
• Consistently meet department productivity and performance metrics.
• Follow HIPAA compliance and TriWest confidentially guidelines.
• Refers beneficiaries to network providers.
• Resolves issues to complete care request.
• Reads and comprehends diagnosis, procedures and requested service on incoming care requests. Assists in producing trend reports to improve workflow efficiency and system functions to recommend possible solutions to management.
• Assists with resolving data quality issues by identifying, documenting, and communicating quality issues.
• Resolve process issues to ensure high quality service levels throughout TriWest. Seeks advice and escalates issues or problems as warranted.
• Processes referrals for Behavioral Health, Specialty Care, Durable Medical Equipment, Inpatient Admissions, Military Treatment Facilities, and Urgent referral and authorization requests.
• Assesses electronic documents to ensure appropriate entry into the medical management system.
• Works with standard coding systems including: standard medical taxonomy, ICD-10, CPT and HCPCS codes.
• Verifies beneficiary eligibility and ensures appropriate referral procedures are followed for the various types of TRICARE beneficiaries.
• Ensures procedures are followed for referrals based on beneficiary eligibility type, geographical location, and on the provider's request.
• Processes authorization requests and referral requests in the on-line medical management system.
• Initiates the Knowledge Skills and Abilities process for the referrals, to ensure appropriate care is being requested at Military Treatment Facilities.
• Communicates with other departments, medical providers, and beneficiaries to clarify documentation prior to processing.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Communication / People Skills

Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy

Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility

Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Empathy / Customer Service

Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.

Multi-Tasking / Time Management

Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills

Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis

Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Technical Skills

Knowledge of TRICARE and the Military Health System programs; ability to use CHCS booking procedures, ATC standards and established clinic capability/booking protocols.

Working Conditions

• Ability to cover any work shift
• Ability to work overtime, if needed
• Onsite: Works within a standard office environment
• Remote: Private and secure workspace and workstation with high speed internet is required
• Extensive computer work with prolonged sitting, wearing of headsets, typing, speaking on a phone

Company Overview

Taking Care of Our Nation’s Heroes

It’s Who We Are. It’s What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve!

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $51,000 - $54,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.