Address: 2001 Gary Ave. Wheaton, IL. 60187

Hours: Monday-Friday, 8:30am-5:00pm

Major Responsibilities:

• Coordination of the Referral Process
  •       1)Collects all referrals from medical staff daily and obtains any necessary approvals from attendings.
  •     2)Works in all aspects of the referral process, including processing referrals for patients based on primary care physician orders and follow up specialists service recommended.
  •     3)Generates necessary correspondence or calls to patients, physicians and office staff, managed care organizations or vendors requesting additional information and requirements for referral authorization.
  •     4)Communicates with appropriate Physician, nursing staff and patients regarding follow-up status of referrals.
  •     5)Prepare correspondence, input referral information in the automated system, collects additional medical necessity supporting documentation and provide to appropriate parties for approval.
  •     6)Attend PHO and other vendor meetings as required to discuss changes in processing requirements.
  •  7)Identifies potential problems (i.e., labs, x-rays, procedures, and other physicians) with payment of charges from referral by communication with PHO and other managed care specialists.
• Reviews all payor requirements by type of service and organizes materials to ensure appropriate referral and that steps are followed to avoid claims denials.
  •     1)Investigates diagnosis codes and medical necessity guidelines to determine if appropriate based on payor guidelines.
  •     2)Discusses any discrepancies with physician for correct coding of referral.
  •     3)Provide correct codes both ICD9 and CPT and explains coverage to ordering physician.
  •     4)Input codes into automated system and discuss any certification requirements with vendor’s nurse certification specialist.
  •     5)Monitors approval status and resubmit request as necessary.
  •     6)Identifies need for appeal process with insurance companies and Medicare and initiates process.
• Participate in education and eligibility problem resolution.
  •     1)Works with attendings and nurses in the education of physician office staff on referral procedures.
  •     2)Acts as a resource to customers and help resolve referrals, claims and eligibility issues.
  •     3)Communication with manager, program director, other health care professionals, and various staff in a positive fashion in order to promote patient satisfaction, quality services delivered and resolution of issues.
  •     4)Verify eligibility of patients including problem resolution with Advocate MSO and various managed care organizations.
  •     5)Identifies and maintains appropriate communication with supervisor involving problems and observations in course of daily operations.
  •     6)Other duties as needed.
• Establish controls and a tickler system set-up to see if services are obtained. Maintain tracker to ensure:
  •     1)Patient received the services ordered before termination of the referral.
  •     2)Patient have proper paperwork before going to the referral site.
  •     3)Results are received from the specialist prior to the patient’s next appointment.
  •     4)Respond as needed to same day request from patient, if patient urgently needed to see a specialist or forgot paperwork.
• Assures that referral documentation is filed in the medical record and physician sees clinical results of the referrals based on a tracking system put in place.
  •     1)Collect all faxed or mailed in consultant reports for referred patients.
  •     2)Sort and place in physician mail boxes for review with patient chart.
  •     3)Assure that physician has signed off acknowledging review.
  •     4)File data in patient chart and re-file the record in the medical records file room.

Education/Experience Required:

• H.S. diploma or G.E.D.
• 3-4 years experience in a managed care organization, hospital or physician’s office with 1 year referral experience
• Excellent medical terminology comprehension and its effective usage
• Completion of 1 Medical Terminology class with certificate of completion.

Knowledge, Skills & Abilities Required:

• Excellent communications skills.
• Computer literate
• 35 wpm keyboarding preferred
• Experience with IDX, Windows and other I.S. systems
• Good organizing skills.
• Good problem-solving skills
• Ability to handle difficult calls and maintain professional conduct
• Excels as a team player
• Flexible with job responsibilities

Physical Requirements and Working Conditions:

• Ability to work independently. • Ability to handle stress and high workload volumes. • Ability to communicate denial of services to members and providers.
• If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.