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Position Summary
 Position Summary:

The Health Management Referral Coordinator is responsible for coordination and processing of out-of-network referral, authorization, and appeal requests to determine whether the out-of-network service can be provided within the Martin’s Point network. The Referral Coordinator serves as liaison between members and the plan to facilitate access to care within health plan guidelines. The Referral Coordinator may also review, enter, and update referral and authorization requests. The role provides administrative support to the Health Management Department clinical staff and works collaboratively with all Health Management Department (HMD) staff and other Health Plan Operation department staff.
Job Description

Key Outcomes:

Available on a phone queue from 8 a.m. to 4:30 p.m. to receive referral and/or authorization requests as well as answer general referral and/or authorization questions from members and providers.Assemble information concerning patient’s clinical background and referral needs. Per referral guidelines, provide appropriate clinical information to Utilization Review Nurses.Makes outbound calls to obtains supporting documentation from referring providers and clinically appropriate specialists that supports whether care requested can or cannot not be provided within the Martin’s Point provider network.Researches information, depending on type of out-of-network specialty care requested, to find similar or like specialists who are contracted with the member’s plan.Review details and expectations about the referral with members.Coordinates scheduling with participating specialists to facilitate timeliness of care and adherence to access to care standards.Ensure that referrals are addressed in a timely manner per contractual/regulatory standards.Manages assigned referral/ authorization queues by reviewing, entering, and processing care requests per HMD’s guidelines/ workflows and contractual/ regulatory standards.Uploads faxes and required information into the medical management system.Tracks out-of-network referrals for Network follow through.Complies with all contract requirements and organizational/department standards regarding referrals, authorizations, and member/provider communications including notifications.Participates in and contributes to Health Management Department meetings and process improvement initiatives.

Education/Experience:

Associate degree or equivalent education and experience2 years of managed care experience including experience in a call centerExperience with medical terminology, CPT, ICD-10, and HCPCS coding a plus

Required License(s) and/or Certification(s):

Medical Assistant Certification a plus

Skills/Knowledge/Competencies (Behaviors):

Demonstrated an understanding of and alignment with Martin’s Point Values.Basic knowledge of medical terminology, current healthcare benefits and managed care insurance plansBasic knowledge of Microsoft Word and ExcelKnowledge of CMS and NCQA regulations a plusDemonstrated technical skills in use of office systems, electronic heath records, and databasesStrong organizational skills (ability to prioritize and multi-task in a high-pressure environment while maintaining focus on organizational objectives)Ability to take direction from multiple individuals and prioritize tasks appropriately to meet priorities and deadlinesAbility to handle confidential and sensitive information in a discreet and professional mannerCommunicates effectively with both internal and external customersAbility to function independentlyCritical thinking: Can identify root causes and suggest creative solutionsTakes appropriate initiative while soliciting input/advice appropriatelyAbility to collaborate with all internal departments and staff with dedication to customer satisfaction

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org