Referral Specialist
On-siteSan Marcos, California, United States
Job Summary
Coordinate and process medical, dental, and optical referrals and authorizations for PACE participants while navigating CPT, HCPCS, and ICD-10 codes to ensure timely specialty service access. Interface with primary care providers and specialty offices to obtain documentation, manage electronic medical record functions, and oversee the transfer of medical records between providers. Conduct medical record audits, request additional records for review, and utilize clinical judgment to determine best approaches for urgent and non-urgent patient care needs. Maintain HIPAA standards, adhere to departmental policies, and bring process improvement ideas to the Supervisor. Work in a fast-paced environment with a multi-disciplinary team to support seniors aging in place in North County San Diego.
Required Qualifications
- High school diploma or GED equivalent
- One year of health care experience working with frail and/or chronically ill elderly population
- One year experience in a healthcare setting including front and back-office exposure
- One year experience in referral and authorization processes for managed care insurance platforms
- Must have excellent written and verbal communication skills
- Ability to interact clearly and effectively with both internal and external customers
- Prior exposure working with an electronic medical record platform
- Proficient in Microsoft Word and Excel
- Ability to multi-task, be flexible, ensure accuracy, and meet changing priorities in a fast-paced, high-workload environment
- Ability to work with others as a core centralized team
- Maintain HIPAA standards
- Adhere to policies and procedures that govern the confidentiality of healthcare sensitive information
- Medical clearance for communicable diseases
- Up-to-date immunizations
- Successful pre-employment drug screen
- Successful background check
- Successful physical assessment
- Must demonstrate regular attendance and punctuality
- Ability to use clinical and administrative judgement under regulations to determine best approach for both urgent and non-urgent patient care needs
- Ability to navigate and utilize multiple functions from an electronic medical record platform
- Understanding of universal codes such as Current Procedural Terms (CPT), Healthcare Common procedure Coding System (HCPCS), and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- Understanding of International Classification of Diseases (ICD-10)
- Ability to obtain, receive, and transfer participants' medical records to and from providers outside of PACE
- Ability to ensure proper medical release forms are complete
- Ability to scan any paper documents into the electronic medical record
- Ability to conduct medical record audits
- Ability to request additional medical records from specialty offices and clinics
- Ability to maintain established departmental policies and procedures
- Ability to enhance professional growth and development through participation in educational programs
- Ability to attend meetings as required
- Ability to participate in committees as directed
- Ability to demonstrate appropriate level of time management
- Ability to maintain good interpersonal interactions with clients
- Adherence to Gary and Mary West PACE core values and behaviors of Excellence, Empowerment, Integrity, and Respect
- Adherence to all GMWP Policies and Procedures
- Adherence to GMWP Safety Policies and Procedures
- Adherence to OSHA safety guidelines
- Ability to bring issues and process improvement ideas to the attention of the Supervisor
- Ability to maintain verbal and written skills required for the position
- Ability to complete annual trainings as required
- Adherence to Company Dress Code Policy
Desired Qualifications
- Medical Terminology Certification
- Medical Assistant Certificate
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