Prior Authorizations and Referral Management Representative

St. Charles Health System; Bend (OR); On-site; USD 40,000 - 55,000; Full time

Job summary

St. Charles Health System in Bend, Oregon seeks a Prior Authorizations and Referral Management Representative to coordinate authorizations and referrals for services, testing, specialty care, diagnostics, and surgery.

This role acts as a liaison between patients and clinicians to facilitate care coordination. You will perform scheduling coordination with surgery, clinics, and ancillary departments, update systems with eligibility and approvals, and support patient education while maintaining

Qualifications

• Minimum one year in hospital, clinic, or medical insurance billing office.
• Basic understanding of medical coding.
• High school diploma; college coursework preferred.

Responsibilities

• Coordinate prior authorization and referrals for services, testing, specialty care, diagnostics and surgery.
• Validate patient health plan coverage and obtain accurate benefit eligibility in the system.
• Communicate provider, facility, and order information to health plans.
• Notify health plans and obtain financial clearance for planned care.
• Coordinate patient assistance programs with patients and providers.
• Utilize internal and external systems to request and coordinate prior authorizations and referrals.

Skills

Medical billing

Pre-authorization

Claims processing

Healthcare admin

Customer service

Education

High School Diploma

College coursework preferred

Tools

EHR systems

Insurance portals

Scheduling software

Job description

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.
• Facilitates 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