Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:

Reports to the Central Patient Access Supervisor and serves as a primary point of contact for high-volume inbound calls and referral/authorization requests from physician offices and internal departments. Processes internal and

external referrals by obtaining and submitting medical records, verifying eligibility, securing benefit coverage determinations, guiding network steerage, and resolving referral issues. Work is primarily telephonic, computer-based, and office-based, and directly supports timely, appropriate patient care and health promotion by ensuring accurate, payer-compliant authorizations.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

• Receives and documents, telephonic, and electronic requests for referrals from Primary Care Physicians, Specialists and Ancillary providers

• Contacts review organizations and insurance companies to obtain prior approval requirements and submit appropriate documentation.

• Verifies member eligibility and basic benefit coverage levels including obtaining information on coordination of benefits and third-party liability as appropriate.

• Maintains a current working knowledge of all Health Plan carrier requirements for referral request authorizations and approval path requirements. (Pre-Determinations and Peer to Peers)

• Investigates and obtains from providers, missing medical information required for referral submission.

• Utilizes computer resources to determine provider networks.

• Per referral guidelines evaluates each referral request to ensure the referral request including codes, place of service, service type, provider and all required medical information is available for submission to insurance carriers.

• Applies knowledge and application of ICD-9 and CPT coding, as well as medical terminology for appropriate communication with physicians and providers

• Performs data entry/processing of referral requests through the EPIC system, and edits referral notes with appropriate information as outlined per department procedures.

• Adheres to hospital policies and procedures.

• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.

• Adheres and comply with customer service standards and dress code as set forth by the hospital and the department.

• Understand and apply payer rules to include commercial, Medicaid/CHIP, Medicare; OON vs INN rules; pre-auth vs pre-cert vs notification.

• CPT/HCPCS, ICD-10-CM, modifiers (incl. therapy, radiology, surgical bundles), NCD/LCD & payer medical-necessity criteria.

• Site-of-service & modality requirements (OP hospital, ASC, free-standing, telehealth).

• Coordination points: clinic workflows, surgery scheduling, imaging, pharmacy/infusion, DME, rehab, SLP/PT/OT.

• Privacy & compliance: HIPAA, minimum necessary, consent and minor/guardian nuances.

• EHR/PM and clearinghouse fundamentals; payer portals (Availity, UHC, BCBS portals, TMHP, etc.).

• Other duties as assigned

• Functions as a resource to physician/provider offices regarding steerage, referral process questions and education on Health Plan authorization submission requirements.

• Provides source of referral and prior approval requests with timely notification of approval or denial decisions through designated communication routes.

• Resources Senior Authorization Coordinator or Supervisor/Manager for review of complex referral requests and issues

• Works with Physician offices to provide ongoing education regarding referral process and requirements.

• Provides input to Team Lead and Supervisor/Manager regarding improvements to operating practices

• Assists with orientation and training of new staff

Customer Service Duties

• Answers the department telephone immediately or within three rings utilizing courtesy and patience

• Listens to customer needs and takes appropriate action as indicated

• Respond to urgent emails and voicemails promptly

• Gather patient demographic and financial information in a kind and courteous manner

• Document telephone encounters.

• Conduct warm transfers as needed

• Respond to urgent emails and voicemails promptly, and respond to non-urgent emails and voicemails at the end of the day

• Place outbound calls to referring providers or guardians (for self-referrals) to obtain missing and validate existing information

• Facilitate referral intake

• Complete any additional ancillary tasks

Patient Accounting Duties

• Accurately create patient encounter in patient accounting systems utilizing the appropriate patient search criteria and interview method

• Verify patient’s insurance benefit and document findings, this process should be completed in the appropriate timeframe for the service being provided

• Refer cases for financial screening as indicated

• Complete all authorization procurement work functions as indicated

• Read orders, match CPT/DX, validate medical necessity, spot missing documentation.

• Documentation: clear, concise auth notes; attach evidence (guidelines, MD notes); version control of templates.

• EHR work queues, tasking, payer portals, fax/e-fax tools; Excel/Sheets for trackers; Outlook/Teams etiquette.

• Communication: concise emails to clinics and payers; parent/guardian education on auth status and expectations.

• Problem-solving: navigate ambiguous policies, escalate edge cases, craft payer-specific justifications.

• Time management: handle high-volume queues, SLAs, and stat cases without losing accuracy.

• Data use: read denials reports, find root causes, update templates to prevent repeats.

• Accurately collect and enter patient demographics into patient accounting systems as indicated

• Populate referral data elements into Epic Referral Record as indicated

• Complete documentation in Epic according to Driscoll Health System and department documentation guidelines

• Revenue cycle basics: denials taxonomy, timely filing, retro-auth risk, ABN/financial clearance.

Quality Assurance Duties

• Review schedule/pre-registrations/registrations to identify potential duplicate medical record numbers.

• Update data discrepancies in Epic.

• Identify patients with multiple same day visits to match demographic and insurance data for each pre-registration.

• Review patient demographic and financial data to ensure accuracy

• Validate verification and documentation of insurance eligibility and coverage for anticipated procedures.

• Validate insurance authorizations was obtained from referring physicians and payors when necessary/appropriate.

• Reviews pre-registration list for cancellations and notify department as indicated.

• Identify patients that are missing any pre-registration items

• Check for referral minimum data set elements

EDUCATION AND/OR EXPERIENCE:

HS diploma/GED required; 2+ years in patient access, scheduling, billing, or utilization review; or equivalent combination of education and experience.

Working experience of Epic system preferred.

Working knowledge of CPT/ICD-10 and at least two major payer portals.

Proficient computer navigation skills, with basic/advanced Microsoft Office/Outlook and intra/internet experience.

Medical Terminology Knowledge required.

Experience in a fast pace telephonic, production-oriented and metric driven work environment.

Experience working with physicians and clinical staff in a medical or clinical setting.

Specialty experience (cardiology/cath, infusion/high-cost meds, imaging/surgery).

Prior denials/appeals or financial clearance experience.