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UPMC continues to comply with governmental guidance related to local, state, and federal COVID-19 vaccination for employment. All employees and affiliated staff of UPMC entities are considered essential health care workers and will be accountable to follow the Centers for Medicare & Medicaid Services (CMS) federal vaccine mandate. To be compliant with the federal mandate, employees must complete the approved vaccination dosage regimen currently defined by the federal government. Compliance with the federal mandate is encouraged before hire and is required after employment begins. Medical and religious exemption requests may be submitted for consideration.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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Sr. Insurance Referral Coordinator

  • Job ID: 480485107
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Pinnacle Health Medical Services - Specialty
  • Department: UPMC West Shore Ortho
  • Location: 1830 Good Hope Road, Enola PA 17025
  • Union Position: No
  • Salary Range: $17.52 to $26.27 / hour

Description

Purpose:
Responsible for coordination of the referral process within PHMG. Assist and educates the patients and providers on various policies, procedures, and benefits, related to the need for referrals. Pre-certifies diagnostic testing, as required by the patient's insurance. Educates patients and providers on various policies, procedures and benefits related to the need for referrals. Coordinates referrals with patients and specialist's offices. Serves as a liaison between patient, physician and insurance company, consistently performing activities in a friendly, courteous and professional manner. The Sr Insurance Referral Specialist will be responsible to process referral/authorizations for greater than 3 specialties and multiple geographical locations

Responsibilities:

 

  • Other duties as assigned
  • Filing/Scanning
  • Accurately schedules appointments with attention to all scheduling criteria
  • Utilizes electronic referral services as available.
  • Assists patients with billing questions related to referrals, and communicates patient billing inquiries to the Professional Billing Office.
  • Maintains inventory of all appropriate insurance forms, coding reference materials and supplies.Mails any insurance forms to appropriate parties.
  • Investigates grievances that are submitted to insurers by members.
  • Pre-certifies procedures and inpatient admissions with insurance, as necessary.Provides necessary patient medical information to insurance upon request.Reports non-compliant members to the Operation Specialist.
  • If appropriate, properly instructs patients on test preps
  • Maintains up-to-date listing of all network providers.Documents all referrals on patient medical record.Maintains referral log.
  • Monitors referrals to ensure patients stay within network. If patient goes out of the network, coordinates with insurance to get patient back into network.
  • Transcribes Epic orders as indicated by the ordering provider
  • If requested, arranges members surgeries, pre-admission testing, DME, and diagnostic tests.
  • Completes referral forms. Sends referrals to specialists for members, if necessary.Obtains authorizations from providers and insurances, as appropriate.Coordinates referrals with specialist's offices in and outside of the local area.
  • Arranges in-service meetings with managed care organizations representatives for the staff as needed.
  • Conducts periodic updates during staff meetings.Attends meetings and training sessions provided by insurers.
  • Maintains up-to-date information on policies and procedures, billing information, and health care benefits.Handles patient inquiries related to referrals.
  • Educates members, providers, and office staff on the policies and procedures of the different insurances, related to the referral process
  • Maintains the Managed Care Share Drive.
  • Attends billing/insurance meetings when appropriate.Attends customer relations, continuing education classes when appropriate.Provides training to new staff, and answers any questions that may arise.Conducts periodic update meetings with staff.
  • Coordinates referral staff in performance of daily functions.

 

Qualifications

  • High school graduate or equivalent
  • Minimum of 5 years experience in a physicians office or out-patient facility.
  • Critical thinking skills and ability to analyze and troubleshoot issues that may arise.
  • Knowledge of medical terminology, anatomy, disease processes, CPT and ICD-9 coding, and managed care policies and procedures.
  • Knowledge of Epic Cadence
  • Knowledge of Windows software, Word and Excel.
  • Knowledge of Epic referrals
  • Accuracy and attention to detail are extremely important.
  • Must possess strong organization and communication skills and be able to work independently.
  • Must be proficient in all areas of the department to include specialty and diagnostic referral processes, high priority referrals and InBasket tasks for all specialty and geographic areas supported by the PHMG Central Referral Team.
  • Successfully completed the 6-month training in the Central IRS II job and approved by Management to move into the Central Sr. IRS position.
  • 3-5 years of experience, time managment skills, ability to manage change preferred.
  • Knowledge of insurance authorization, surgery, imaging, visco preferred.
  • Identify insurance lines and requirements to obtain authorizations preferred.


Licensure, Certifications, and Clearances:
Clearances must be dated within 90 days.
 

  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct