Coord, Referral

Job Summary:

Responsible for initiating and completing Internal/External Referral requests received through Phone, Fax, Health Connect and On-Line Affiliate Link. Initiates and completes data entry utilizing a standardized documentation template along with established policies and procedures. Provides initial review of benefits and eligibility for services requiring authorization. Assigns or ensures correct ICD-10, HCPCS and CPT codes have been entered. Responsible for notifying members regarding referral/authorization orders, eligibility/benefit questions and scheduling appointments for external referral consultations, tests &/or procedures. Supports the daily activities of the QRM/Post-Acute Regional Review Team.

Essential Responsibilities:

• Responsible for initiating and completing internal/external, pre-certification referral requests received.
• Provides data entry on all authorization requests based on a documentation standard template with established policies and procedures for the purpose of clinical review
• Performs data entry and approval of all pre-certification notification only requests (no clinical review) utilizing established criteria and guidelines and documenting according to standard templates and with established policies and procedures.
• Reviews eligibility and benefits of the member, utilizing established criteria and guidelines and coordinates with member services and benefits department.
• Assigns appropriate diagnosis and procedure codes following coding guidelines for ICD-10, CPT and HCPCS codes for all (pre-certification) Referral requests.
• Aids specialists or primary care practitioners and office staff on coding and target review questions.
• Maintains current knowledge of both coding and targeted review items to ensure that the right requests are initiated and sent to the correct specialty review per contract and benefit guidelines and adheres to time frame specified by Kaiser Permanente standards (routine, expedite, urgent, State and Federal.
• Ensure coding is completed correctly on all requests to meet all regulatory guidelines and audit standards which will result in compliance and correct reimbursement.
• Once data entry is complete a copy of the referral form is sent to the consultant via the member or fax. Assists and educates members by answering questions regarding referral and authorization process. Assists and educates the external consultants with questions and concerns with the referral process in the medical office.
• Maintains effective interaction/communication with physicians and their staff as necessary to gather information for referrals as needed.
• Responsible for the support of operational activities for the QRM review team.
• Assists the Referral Leadership with preparation and running reports and other duties as assigned
• Forwards authorization requests (live caller or documented record) requiring a clinical review to the appropriate review staff/team.
• Provides verbal notification in accordance to policy and procedure for members and providers with respect to the outcome of their requested service.
• Provides information to the member regarding location of consultants office, address, and phone number.
• Manage incoming Right Fax physician requests by sorting, entering into authorization system and assigning to correct specialty reviewer.
• Remains knowledgeable of contract benefits, eligibility guidelines, and current State and Federal regulations that affect managed care and utilization management.
• Interacts with Physicians, staff and team members as necessary to gather required information needed for clinical reviews.
• Maintains excellent customer service and professionalism with providers, members and team members always.
• Maintains department productivity standards and accuracy in data entry.
• Maintains effective interaction/communication and working relationships with members of the medical staff, complex case managers, regional review RNs, and other QRM staff to facilitate the general review process. Also, works cross functionally with other departments such as the Kaiser Permanente Medical Offices, Customer Services, Claims, Provider Relations, Appeals and Risk Management, in striving to meet organizational goals and objectives.
• Investigates, identifies, and reports problems and inefficiencies in existing systems and recommends changes when appropriate to the Referral Leadership.
• Knowledgeable and compliant with Regional and QRM department specific personnel policies and procedures.
• Develops and maintains an awareness of how to report compliance issues and concerns
• Identifies need for social services intervention and refers the member to KP social workers as appropriate.
• Maintains complete and accurate data entry for all internal/external, pre-certification referrals into Epic Tapestry based on policies and procedures.