Prior Authorization and Referral Management Rep

St. Charles Health System Inc.; Redmond, Northern (OR, KY); Hybrid; USD 30,000 - 41,000; Full time

Job summary

St. Charles Health System is seeking a Prior Authorizations and Referral Management Representative to coordinate pre-authorization and referral workflows across ambulatory services in Redmond, Oregon.

You will liaise between patients, providers, and health plans, ensuring accurate benefit verification and timely authorizations. The role emphasizes scheduling coordination with surgery, specialists, and clinics; you will maintain patient information in the EMR and related systems, educate patients

Qualifications

• Required: High School diploma or GED.
• Preferred: College level coursework.
• Minimum of one year experience in hospital, clinic, or medical insurance billing
• Basic understanding of medical coding

Responsibilities

• Coordinate prior authorization and referral workflows.
• Confirm and validate patient health plan coverage and obtain eligibility.
• Communicate provider, facility, and order information to health plans.
• Assist with patient education and follow up regarding prior authorizations and referrals.
• Schedule coordination with surgery, specialists, and clinics.

Skills

Communication

Organization

Customer service

Multi-tasking

EMR system

Excel

MS Office

MS Teams

Education

High School diploma/GED

College coursework preferred

Tools

MS Office

Excel

MS Teams

EMR system

Job description

Pay range: $22.30 - $30.11 Surgical Specialists - Remote/Hybrid - Redmond, Oregon

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION TITLE: Prior Authorizations and Referral Management Representative

REPORTS TO POSITION: Applicable Ambulatory Access or Outpatient Clinic Leader

DEPARTMENT: Patient Access Services / St. Charles Clinic

DATE LAST REVIEWED: October 2024

OUR VISION: Creating America’s healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY

Patient Access Services is a support services division of St Charles Health System. Patient Access serves as a liaison to inpatient and hospital-based outpatient departments. Ambulatory Access serves as a liaison to ambulatory outpatient departments by providing scheduling, registration, prior authorization, medical record, population health outreach, and project management support. We encourage collaboration between clinical and non-clinical staff to ensure we are providing our community with comprehensive and compassionate health care.

POSITION OVERVIEW

The Prior Authorizations and Referral Management Representative will be responsible for coordination of prior authorization and referral processes for patients being referred for services, testing, speciality care, diagnostic procedures, and surgery. This role acts as a liason between patients and the professional staff by facilitating coordination of care responsibilities. Extensive scheduling coordination with surgery department, specialist and ancillary departments. Prior Authorization and Referral Management Representatives’ home department may be a specific centralized location that is supported by Patient Access Services, or in a SCHS outpatient clinic supporting a single specialty. This position does not supervise any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES

Must be able to multitask and prioritize workflows; engage providers, care team, and patients in the prior authorization process. Confirms and validates patient health plan coverage and obtains accurate benefit eligibility and coverage. Makes appropriate system updates to coverage and benefits accurately. Communicates appropriate provider, facility, and order information to health plan as part of the prior authorization and referral process. Notifies health plan and gains financial clearance for plans for patient to undergo a course of care requiring prior authorization. Coordinates and supports providers with medication authorizations. May coordinate patient assistance programs with patients and providers. Utilizes internal and external systems to appropriately request and coordinate prior authorization and referrals for patient care. Faciltates the scheduling of patients with internal and external departments, clinics and hospitals. Updates and annotates systems with current and accurate information regarding requests for prior authorizations and referrals. Tracks, updates and investigates current orders and tasks; managing orders through the system to provide up to date and accurate information. Monitors system referral and authorization and patient work queues and lists to ensure each service or consultation order is managed, updated appropriately and accurately and routed for scheduling and completion. Obtains pertinent documentation from provider, facility and patient to ensure accurate prior authorization and patient assistance requests. Effectively communicate with provider, care team members and patients regarding authorizations, scheduling needs, insurance benefits, eligibility, etc. Assist with patient education and follow up regarding the prior authorization and referral processes. Oversees the facilitation of scheduling and appointments when referral is required on behalf of patient. Ability to work as part of a Care Team with providers and clinical staff. Supports the vision, mission and values of the organization in all respects. Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change. Provides and maintains a safe environment for caregivers, patients and guests. Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings. Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION

Required: High School diploma or GED. Preferred: College level course work.

LICENSURE/CERTIFICATION/REGISTRATION

Required: N/A Preferred: N/A

EXPERIENCE

Required: Minimum of one year experience working in hospital, clinic, or medical insurance billing office, performing duties and responsibilities related to medical billing, pre-authorization, claims processing, or a related area of expertise. Basic understanding of medical coding. Preferred: N/A

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION

Must have excellent communication and organizational skills with ability to interact with a diverse population and professionally represent St. Charles Health System with internal and external customers. Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions. Must adapt quickly to frequent process changes and improvements. Is reliable, engaged, and provides feedback to inform process improvement. Attends all department, team, and company meetings as required. Requires exceptional critical thinking and analytical skills with the ability to work under minimal supervision. Requires strong communication, customer service, interpersonal skills and telephone etiquette. Ability to prioritize workflow according to pre-set instructions. Strong teamwork and collaborative skills. Ability to multi-task and work independently. Attention to detail is essential. Performs basic math (add, subtract, multiply and divide) calculations. Performs intermediate to advanced math (analysis, statistics, significant data, or number manipulation). Intermediate ability and experience in computer applications, specifically electronic medical records system, MS Office, MS Teams, and Excel.

PHYSICAL REQUIREMENTS

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level. Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation. Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing. Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pressing or pulling 11-15 pounds, operation of a motor vehicle. Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level. Exposure to Elemental Factors Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface. Blood-Borne Pathogen (BBP) Exposure Category No Risk for Exposure to BBP Schedule Weekly Hours: 40 Caregiver Type: Regular Shift: First Shift (United States of America) Is Exempt Position? No Job Family: REPRESENTATIVE Scheduled Days of the Week: Shift Start & End Time:

ST. CHARLES HEALTH SYSTEM is a private, nonprofit organization, dedicated to providing high-quality care and the latest in health care technology to the communities it serves. Headquartered in Bend, Ore., St. Charles is an integrated delivery system, with a strong focus on population health, that provides a full range of evidence-based health care services within a 32,000-square-mile area in Central and Eastern Oregon. The health system owns and operates a trauma level II, tertiary referral center in Bend, a trauma level III, type B rural hospital in Redmond, and trauma level IV critical access hospitals in both Prineville and Madras. As the largest employer in Central Oregon, St. Charles Health System and St. Charles Medical Group care for our communities in more than two dozen outpatient clinics and in more than 20 specialty areas of medicine.

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