Senior Referral Specialist

TriWest Healthcare Alliance Corp.; Phoenix (AZ); Remote; USD 47,000 - 49,000; Full time

Benefits offered by this job

Medical, Dental and Vision Coverage

Paid time off

401(k) Retirement Savings Plan (with 2

Disability insurance

Job summary

TriWest Healthcare Alliance seeks a qualified specialist to perform non-routine specialty processing and ensure accurate authorization data entry from various sources. The role may operate in a virtual environment, with HIPAA confidentiality emphasized.

Required are U.S. citizenship, a DoD background investigation, a high school diploma or GED, and 2+ years in health care operations involving data entry or customer service. Proficiency with Microsoft Office is preferred.

Qualifications

• U.S. Citizenship required for DoD contract.
• High school diploma or GED required.
• 2+ years in health care operations with data entry or customer service.
• Experience with processing specialty referrals and related workflows.
• Proficient with Microsoft Office applications.

Responsibilities

• Process specialty referrals with accuracy in the medical management system.
• Assess authorization/referral requests for proper data entry.
• Ensure compliance with HIPAA and confidentiality guidelines.
• Reference coding systems (ICD-10, CPT, HCPCS) as needed.
• Maintain productivity and meet department performance metrics.
• Coordinate with providers and beneficiaries to clarify documentation.

Skills

Communication

Teamwork

Detail oriented

Adaptability

Education

U.S. Citizenship

High School Diploma or GED

2+ years healthcare data entry or customer service

Experience processing referrals

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

Perform non-routine, specialty processing. 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.
• 2+ year experience in health care operations performing data entry or customer service
• Demonstrated proficiency and experience in processing specialty referrals
• Experience with Microsoft Office

Preferred

• Referral and authorization processing experience
• Knowledge of medical terminology obtained through medical assistant certification or experience interpreting and applying ICD and CPT codes
• Managed Care experience
• TRICARE experience
• Veteran or military spouse or military affiliated

Key Responsibilities

• Perform specialty team processes such as ROFR, Non-Network, Prime Travel and Research and Repair.
• 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.
• Follows 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 function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

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 headset, typing, speaking on a phone

Company Overview

Taking Care of Our Nation's Heroes.

Do you have a passion for serving those who served?

It's Who We Are. It's What We Do.

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

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

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

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• 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 $47,000 - $49,000 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.