Description

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.

Qualifications

• High school graduate or equivalent
• Minimum of 3 years 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:
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

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.