Behavioral Health Clinical Referrals Specialist

Description

EEO-1: Administrative Support Workers

POSITION SUMMARY

Promotes timely and appropriate referrals for behavioral health services by assisting behavioral health coordinators and clinical staff in the processing of inpatient and outpatient behavioral health referrals.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.

RESPONSIBILITIES

• Maintains internal operations and compliance with established standards and timelines by receiving admission notifications and outpatient referral authorization requests via mail, fax, or telephone; determining member eligibility and reviewing plan benefits; entering appropriate CPT and/or ICD codes and referral/admission information in the Utilization/Case Management system; forwarding request to appropriate behavioral health coordinator or clinical staff for review, authorization and length of stay determination; following policies and procedures; obtaining additional clinical documentation from primary care provider or specialist, as requested by behavioral health coordinator or clinical staff.
• Provides customer services to external/internal customers by assisting Community Health Group (CHG) contracted facilities, primary care provider sites, specialty and ancillary providers, and members and their families with information regarding access to health care services; utilizing clinical staff as a resource, reviewing plan benefits and prior authorization requirements with customers; educating health care providers regarding utilization management process; providing information about special program and community services and transferring callers to other appropriate staff members as necessary; producing and mailing hard copy responses, including non-certified and exhaustion of benefit letters, facility and members as applicable.
• Assists behavioral health coordinators and clinical staff by reporting issues to management; identifying potential over- or under-utilization of services, and gathering data obtained from daily referrals review to assist in reporting primary and specialty care practice patterns; reviewing appropriate coding of services and use of CHG contracted providers; referring questionable referrals for clinical review; assisting behavioral health coordinators and clinical staff with educating primary care providers.
• Facilitates timely referral turnaround by receiving completed admission or referral requests from facility, behavioral health coordinators or clinical staff; entering data and faxing or calling authorization/admission information to appropriate provider.
• Ensures the provision of quality health care by monitoring, in conjunction with behavioral health coordinators, clinical staff and management, member and provider concerns; Potential Quality Issues (PQI), assisting in resolving problems involving access to appropriate levels of care; completing CQI forms and requesting reports; maintaining confidentiality.
• Contributes to the team effort by attending department meetings; giving and receiving feedback; accomplishing related results as needed; assisting behavioral health coordinators and clinical staff in identifying areas requiring policies and procedures; working with behavioral health team in policy development and periodic policy review.
• Maintains filing system by maintaining accurate files of admissions and authorizations by facility/primary care site; retrieving and/or reproducing files as needed; transferring and archiving documents per department protocols.
• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
• Performs other duties as requested by management.

Qualifications

EDUCATION

• High school diploma or equivalent.
• Medical terminology.
• Associates degree in medical field preferred.

EXPERIENCE/ SKILLS

• 2 years customer service and data entry experience in medical field.
• 3 years customer service and data entry experience in a managed care organization preferred.
• Ability to operate a personal computer, UM/CM System/HSD database, telephone, fax, and copier.
• Medical terminology including ICD-10 & CPT coding structures.
• Excellent customer service and communication skills.
• Detail-oriented.
• Bilingual (English/Spanish) preferred.

PHYSICAL REQUIREMENTS

• Prolonged sitting, data entry and telephone use.
• May be required to work evenings and/or weekends.

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action.

Salary : $20 - $22