PACE Referrals Specialist

Position Summary:

Responsible for timely processing, documenting, and follow up of referrals and request for treatment authorizations as requested by the primary physician and contracted network providers/vendors.

Essential Functions of the Job:

• Receives and processes referrals and approvals in alignment with the minimum expectations of CMS.
• Obtains approvals from providers and disseminates information to participants in writing or electronic media.
• Coordinates care within the guidelines of multiple providers.
• Responds to inquiries as to status of authorizations by assessing the request and evaluating the circumstances to provide the correct information.
• Initiates the appropriate documentation of requests from specialties offices for ongoing care.
• Follows-up on missing documentation on submitted authorization requests to obtain sufficient information for request to be reviewed by UM.
• Uses various modules of the computer system to obtain information, query information and process authorizations.

Additional Duties and Responsibilities:

• Maintains established departmental policies and procedures, objectives quality assurance program, safety and environmental. 
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops. 
• Attends meetings as required and participates in committees as directed. 
• Performs other related duties as assigned or requested.

Job Requirements:

Education Required (Minimum level of education):

• High school diploma or GED equivalent

Certifications/Licenses Preferred:

• Medical Terminology, CPC or Medical Assistant

Experience Required (Minimum level of experience):

• 2 years in medical field to include front and/or back office, referral - authorization knowledge, and data processing.
• Preferred: 2 years in health plan of clinic setting. One year of experience with Electronic Medical Record Systems.

Verbal and Written Skills Required to perform the Job:

• Preferred: Bilingual (Spanish/English).
• Good verbal and written communication skills in both languages.

Technical Knowledge and Skills Required to Perform the Job:

• Medical terminology and basic computer.
• Typing of 35 wpm.
• Ability to handle multiple activities simultaneously.
• Be attentive to patient needs and concerns.
• Willing to work with others as a team member.

Equipment Used:

• Personal computer, FAX, e-FAX, EPIC, Adobe Pro, Microsoft office

Working Conditions and Physical Requirements:

• Prolonged sitting position, walking, constant telephone and email communication.
• May be required to work evenings and/or weekends.

Universal Requirements

Pre employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.