Job Title: Referral / Authorization Specialist

(Healthcare Experience REQUIRED)

Location: Must live on West Coast - Pacific Time Zone 

Pay: $20.00 per hour

Work Arrangement: 100% Remote - Temp to Perm. 

Experience Required: 1+ Years of Relevant Experience

Company Overview:

Our organization is committed to enhancing the healthcare journey for our members. We are dedicated to delivering accessible, high-quality care tailored to the unique needs of our communities. As a Referral / Authorization Specialist, you will play a crucial role in ensuring our members promptly receive the services they require.

Summary: We are seeking a highly organized and detail-oriented individual to join our team. The ideal candidate will possess extensive knowledge of prior authorization and referrals processes, medical terminology, and ICD-10 coding. The primary responsibilities include processing faxes, building authorizations, and effectively communicating with healthcare providers. This role requires a strong understanding of medical billing codes, computer literacy, and the ability to ensure compliance with State and Federal healthcare regulations.

Essential Functions:

1. Authorization Processing:

   • Provide accurate and efficient computer entries for authorization requests and provider inquiries through phone, mail, or fax.
   • Verify member eligibility and benefits to facilitate appropriate authorization procedures.
   • Determine provider contracting status and ensure appropriateness for the requested services.
   • Assess diagnosis and treatment requests, assigning appropriate billing codes (ICD-10 and/or CPT/HCPC codes).
   • Verify coordination of benefits (COB) status for members.

2. Inpatient Hospitalization Oversight:

   • Verify and maintain inpatient hospital census, including admissions and discharges.
   • Coordinate with healthcare providers to ensure timely and accurate information exchange.

3. Communication and Triage:

   • Communicate with healthcare providers, both verbally and in writing, to gather necessary information and address inquiries.
   • Triage members and information to the appropriate Health Care Services staff, ensuring seamless workflow.

4. Data Entry and Database Management:

   • Enter relevant data into systems accurately and promptly.
   • Maintain up-to-date and comprehensive records of authorizations and related information.

5. Eligibility and Benefits Verification:

   • Check eligibility for members requiring hospitalization or utilization review for other healthcare services.
   • Verify and communicate benefits information to relevant stakeholders.

Qualifications:

• Proficiency in medical terminology, ICD-10 coding, and prior authorization processes.
• Strong computer literacy and experience with healthcare databases.
• Excellent organizational and multitasking skills.
• Effective communication skills, both written and verbal.
• Detail-oriented with a commitment to accuracy.
• Ability to work collaboratively in a team-oriented environment.

Education and Experience:

• High school diploma or equivalent; Bachelor's degree in a related field is a plus.
• Previous experience in health care services coordination or a related role.
• Familiarity with State and Federal healthcare regulations.

Qualifications:

• Education: High school diploma or equivalent. Additional college coursework in healthcare administration or related fields is advantageous.

• Experience: 1+ year of experience in referral and authorization coordination within the healthcare or managed care sector.

• Technical Proficiency: Proficient in using computer systems and software, particularly Microsoft Office and relevant healthcare management applications.

• Communication Skills: Strong verbal and written communication skills, with the ability to interact professionally with providers and internal teams.

• Organizational Aptitude: Excellent organizational and time-management skills for managing multiple referrals and authorizations simultaneously.

• Attention to Detail: A keen eye for detail is essential to ensure the accuracy of referral and authorization processes.

• Problem-Solving: Effective problem-solving skills to address issues and discrepancies.

• Adaptability: Ability to adapt to changes in policies and procedures.

• Team Player: Collaborative and willing to work as part of a team to achieve shared objectives.