ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Prior Authorizations and Referral Management Representative

REPORTS TO POSITION: Clinic Manager

DEPARTMENT: St Charles Medical Group

DATE LAST REVIEWED: March 28, 2014

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:

St. Charles Medical Group encompasses practices in three Central Oregon counties and numerous specialties including family care, internal medicine, obstetrics and gynecology, pediatrics, immediate/urgent care, cardiology, pulmonology, rheumatology, general surgery, cancer care, and sleep medicine. We encourage collaboration between clinical and non-clinical staff to assure 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 process for patients being referred for specialty care, diagnostic procedures, and surgery. Extensive scheduling coordination with surgery department, specialist and ancillary departments. This position does not supervise other Caregivers.

ESSENTIAL FUNCTIONS AND DUTIES

Confirms patient participation in health plan and obtains accurate benefit coverage.

Communicates appropriate provider and facility information to health plan as part of the prior authorization process.

Notifies health plan and gains financial clearance for plans for patient to undergo a course of care requiring prior authorization.

Coordinates and support providers with medication authorizations. Coordinates 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 auths and referrals.

Tracks, updates and investigates current orders and tasks; managing orders through the system to provide up to date and accurate information.

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 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.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- 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 be able to multitask and prioritize work flows; engage providers, care team, and patients in the prior authorization process.

Must have excellent communication skills and ability to interact with a diverse population and professionally represent SCHS.

Strong team working and collaborative skills

Performs basic math (add, subtract, multiply and divide) calculations

Attention to detail is essential.

Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal

Ability to multi-task and work independently

Intermediate proficiency in Microsoft applications (Word, Excel, Project, PowerPoint, and Access), SharePoint, database management, and document preparation.

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, pushing 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