Referral Coordinator

This is a fully remote position, open to applicants in Texas.

📋 Description

• Offer internal assistance to the Medical Management Department in Outpatient Case Management, ensuring that all referred services are evaluated according to plan specifications and approved criteria.

• Communicate effectively and promptly with management and internal teams.

• Handle all incoming calls from PCPs, specialists, and other providers concerning inpatients, surgeries, and outpatient services, including DME, Home Health Care, and other pre-authorization-required services.

• Coordinate DME with contracted HMO vendors for outpatient services.

• Collaborate with the Inpatient Case Manager on discharge planning for members (DME, Home Health, and Skilled Nursing).

• Oversee and review retro surgical procedures in collaboration with the Manager.

• Understand Health Plan policies and procedures related to pre-authorization, benefits by health plan, and preferred facilities for each plan.

• Input data and manage elective admissions that involve surgical components.

• Ensure adherence to health plan guidelines regarding the reporting of cases/surgeries.

• Work alongside clinical staff to evaluate benefit levels for non-medical denial determinations, ensuring the denial process includes letter and log maintenance.

• Recognize potential stop-loss candidates for monitoring and report to a senior-level manager.

• Implement Innovista guidelines and additional approved criteria specified in the client UM Plan for admission/length of stay criteria to authorize initial and continued inpatient services.

• Perform other assigned duties.

⛳️ Requirements

• High School Diploma or equivalent experience is mandatory.

• A minimum of 2-3 years of relevant professional experience, particularly in managed care and quality.

• Familiarity with InterQual and/or MCG (Milliman) guidelines is advantageous.

• Ability to effectively convey technical and basic business concepts to team members and internal clients.

🏝️ Benefits

• A comprehensive health benefits package that includes subsidized medical insurance, with Flexible Spending Account (FSA), Health Savings Account (HSA), and Health Reimbursement Account (HRA) options, along with dental and vision coverage.

• Assurance of financial security through company-paid benefits such as short-term and long-term disability, employee life insurance, and Accidental Death and Dismemberment (AD&D) policies.

• An annual discretionary bonus to enhance your financial outlook.

• A generous paid time off policy that acknowledges and rewards your loyalty and tenure with the organization.

• Paid company holidays and parental leave, allowing for relaxation and family time.

• Access to our Employee Assistance Program, providing support during challenging times.

• A 401(k) plan with a company match, aiding in your future financial security.

• Opportunities for flexible work arrangements, including remote or hybrid options and potentially adjustable work hours.

• Continuous education opportunities that promote personal growth and development.

• A "Dress for Your Day" policy that encourages comfort and self-expression.

• Access to discounted gym memberships through medical coverage, supporting wellness and health.

• Clear pathways for career advancement and growth, recognizing your dedication and ambition.

• Rewarding employee referral bonuses for bringing in like-minded individuals to our team.

• An open-door policy that promotes direct communication with our CEO and upper management, fostering transparency and inclusivity in our workplace culture.