Purpose:
Responsible for coordination of the referral process within the outpatient sites. Responsible for coordinating specialty referrals and diagnostic testing for outpatient facilities. Pre-certifies diagnostic testing, as required by patient's insurance. Educates the patients on various policies, procedures, and benefits, related to the need for referrals. Coordinates referrals with patients and specialist's offices, and process insurance referrals as required. Acts as a liaison between patient, physician, and insurance company, consistently performing activities in a friendly, courteous, and professional manner. The Insurance Specialist II will be responsible to process referral/authorizations for greater than 3 specialties and multiple geographical locations.
Responsibilities:
- Interacts with physicians, physician extenders, and all fellow employees in a courteous and professional manner.
- Clearly explaining all policies and procedures, answering questions, and providing instruction to patients and family members in an age specific manner.
- Being aware of the individual's needs, receptive to questions and criticism, and willing to offer assistance.
- Protecting each person's legal and moral right to unbreached confidentiality.
- Performs other duties as assigned by manager.
- Utilizes electronic referral and authorization services as available.
- Communicates with insurance offices to authorize services.
- Takes referral requests from patient, specialist, and primary care office.
- Answers telephone in a timely, pleasant, and professional manner.
- Handles appeal requests with insurance company when necessary.
- Coordinates out of network exceptions with insurance company when necessary.
- Provides necessary patient medical information to insurance upon request.
- Obtains authorizations with insurance companies for diagnostic testing.
- Accurately schedules appointment with attention to all scheduling criteria.
- Transcribes Epic orders as indicated by the ordering provider.
- Handles Urgent and ASAP appointment requests in a timely fashion.
- Maintains referral log.
- Documents all referrals in patient medical record.
- Maintains up-to-date listing of all network providers.
- Completes insurance referrals for patient's scheduled appointments.
- Monitors referrals to ensure patients stay within network. If patient goes out of the network, coordinates with insurance to get patient back into network.
- Coordinates appointments for diagnostic testing. Advises patient of test prep if applicable. Obtains insurance for authorization, if applicable.
- Sends appointment request to specialist with appropriate patient records. Processes insurance referral if applicable.
- Coordinates appointments with specialist's offices in and outside of the local area.
- Attends meetings and training sessions provided by insurers.
- Handles patient inquiries related to referrals and authorizations.
- Maintains up to date referral and authorization guidelines and requirements from insurance companies.
- Educates/assist providers on accurate diagnostic test order selection based on current radiology guidelines.
- Educates members, providers, and office staff on the insurance guidelines and requirements, related to the referral and authorization process.
- High school graduate or equivalent
- Minimum of 2 years of experience in a physician's office or outpatient facility.
- Knowledge of Electronic Medical Records/Electronic Health Information systems.
- Knowledge of insurance companies, guidelines and requirements, authorization and referral process and websites.
- Knowledge of medical terminology, anatomy, disease processes, CPT and ICD-9 coding, and managed care policies and procedures.
- Familiar with Windows software, Word and Excel and Outlook.
- Must possess strong organization and communication skills and be able to work independently and within a team.
Licensure, Certifications, and Clearances: - Act 34
UPMC is an Equal Opportunity Employer/Disability/Veteran