Prior Authorizations and Referral Management Representative

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE:                                      Prior Authorizations and Referral Management Representative

REPORTS TO POSITION:         Applicable Ambulatory Access or Outpatient Clinic Leader

DEPARTMENT:                         Patient Access Services / St. Charles Clinic

DATE LAST REVIEWED:          October 2024

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:  Patient Access Services is a support services division of St Charles Health System. Patient Access serves as a liaison to inpatient and hospital-based outpatient departments.  Ambulatory Access serves as a liaison to ambulatory outpatient departments by providing scheduling, registration, prior authorization, medical record, population health outreach, and project management support.  We encourage collaboration between clinical and non-clinical staff to ensure 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 processes for patients being referred for services, testing, speciality care, diagnostic procedures, and surgery.  This role acts as a liason between patients and the professional staff by facilitating coordination of care responsibilities. Extensive scheduling coordination with surgery department, specialist and ancillary departments. Prior Authorization and Referral Management Representatives’ home department may be a specific centralized location that is supported by Patient Access Services, or in a SCHS outpatient clinic supporting a single specialty.

This position does not supervise any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES 

Must be able to multitask and prioritize workflows; engage providers, care team, and patients in the prior authorization process.

Confirms and validates patient health plan coverage and obtains accurate benefit eligibility and coverage.  Makes appropriate system updates to coverage and benefits accurately.  

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

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

Coordinates and supports providers with medication authorizations. May coordinate patient assistance programs with patients and providers.

Utilizes internal and external systems to appropriately request and coordinate prior authorization and referrals for patient care.

Faciltates 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 authorizations and referrals.

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

Monitors system referral and authorization and patient work queues and lists to ensure each service or consultation order is managed, updated appropriately and accurately and routed for scheduling and completion. 

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, eligibility, 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.

Ability to work as part of a Care Team with providers and clinical staff.

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

Supports 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 have excellent communication and organizational skills with ability to interact with a diverse population and professionally represent St. Charles Health System with internal and external customers. 

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

Must adapt quickly to frequent process changes and improvements.

Is reliable, engaged, and provides feedback to inform process improvement.

Attends all department, team, and company meetings as required.

Requires exceptional critical thinking and analytical skills with the ability to work under minimal supervision.

Requires strong communication, customer service, interpersonal skills and telephone etiquette.

Ability to prioritize workflow according to pre-set instructions.

Strong teamwork and collaborative skills.

Ability to multi-task and work independently. 

Attention to detail is essential.

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

Performs intermediate to advanced math (analysis, statistics, significant data, or number manipulation).

Intermediate ability and experience in computer applications, specifically electronic medical records system, MS Office, MS Teams, and Excel.

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

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