Referral Specialist WMCG - Medicine Clinic - Augusta, GA
Wellstar Health Systems

Job Info

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Facility: AU Medical Center, Inc.
Job Summary:

The Referral Specialist is responsible for handling the referral process for specialized procedures in the ambulatory setting, ensuring that appropriate authorizations are requested, received and recorded in tapestry. Acts as the primary source for staff regarding authorizations, insurance plans, and specific procedural codes. The job duties include tracking of the patients and ensuring follow through. This is a clerical position working in a clinic with multiple providers and support staff. Work situations require a poised individual, courteous manner, discretion, organization skills, and good judgment. Knowledge of all department functions and various insurance plan provisions is essential. This position requires extensive interaction with external customers to include other physician offices, insurance plans, and patients. Internal contacts include the nursing staff, providers, and centralized call center staff.

Core Responsibilities and Essential Functions:

Principal Accountabilities
* Coordinates and processes authorizations
* Acts as the liaison between the specialist, primary care physician and insurance carrier to ensure appropriate authorization for specialty procedures. Communicates all insurance concerns to the specialist.
* Ensures all authorizations are requested with appropriate ICD9 / CPT codes and includes clinical data to support request.
* Expedite the authorization process by monitoring and tracking the special procedure database (tapestry).
* Updates tapestry with valid authorization codes, date of service, and insurance contact information.
* Tracks and monitors all clinic authorizations and referrals.
* Documents referrals and all conversations regarding authorization request in the electronic medical record.
* Responds to all patients insurance questions/concerns.
* Responds to all required insurance data requests in a timely manner.
* Advocate for, and generates appeals and troubleshooting patient needs.
* Maintains utilization data on managed care patients.
* Responds to all phone calls from patients, physician offices and insurance plans on referrals made.
* Coordinates all aspects of managed care operations.
* Coordinates review of all clinic authorizations with Patient Care Manager, Providers and support staff as necessary.
* Researches patient eligibility and benefits; corresponding with patient accounts and faxing requested documentation.
* Contributes to the success of the organization by meeting organizational competency expectations and core values (respect, integrity, stewardship, excellence, collaboration and kindness), continuously learning, and by performing other duties as needed or assigned.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• High School Diploma Other or GED Other

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 2 years clerical experience Required or
medical office Preferred or
Experience with CPT and ICD-9 coding Preferred

Required Minimum Skills:

Knowledge of and skill in the use of personal computer and related software.
Knowledge of medical terminology and medical ethics.
Time management, good grammar and spelling, good interpersonal skills.
Ability to deal with difficult people or situations in a professional manner.
Ability to train staff of all levels. Ability to work efficiently under pressure, with a high degree of accuracy.
Ability to work independently and take initiative.
Ability to exercise discretion and maintain confidentiality.

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