Kinsley Power Systems
Referral Management (Non-Nurse) Reviewer
Kinsley Power Systems, Bethesda, Maryland, us, 20811
Zimmerman Associates, Inc. (ZAI)
is seeking to hire multiple
Referral Management (Non-Nurse) Reviewers
to support our contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Region’s premier authority for appointment coordination and referral management services for beneficiaries within the Defense Health Network. Pay Rate:
$23.56 per hour plus $4.93 Health & Wellness Fringe Role and Responsibilities:
Referral Management (Non-Nurse) Reviewers will facilitate centralized product line and specialty referrals for Active-Duty Service Members and TRICARE Prime beneficiaries enrolled at Military Treatment Facilities (MTFs) within the National Capital Region. This is an
onsite opportunity Qualifications / Skills / Experience:
Minimum of an
Associate’s degree
At least
2 years of experience
in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance Referral
U.S. Citizenship required, with the ability to obtain a Public Trust Clearance
Knowledge of medical care criteria such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs), or other evidence-based Military Health
System (MHS) guidelines
Familiarity with medical terminology and ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, and release of medical information protocols
Excellent communication and interpersonal skills
Strong customer service orientation
Understanding of Access to Care Standards within the Direct Care System
Attention to detail, including correct use of deferral codes
Strong organizational skills with ability to prioritize tasks and manage time effectively
Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Access, Outlook) and internet navigation
Essential Tasks:
Review and process referrals for administrative and clinical completeness and appropriateness, completing disposition within 24 hours of referral date Collaborate with appointing centers, case managers, product line nurses, providers, clinics, managed care contractors, and other healthcare team members to ensure appropriate use of Direct Care and civilian network resources Ensure patients are scheduled with the right provider, at the right time and place Review compliance with Specialty Referral Guidelines (SRGs) per IRMAC protocols Complete and return Clear Legible Reports (CLR) to ordering civilian providers within required Return of Favorable Response (ROFR) timelines Manage telephone, written, and electronic communications regarding specialty appointments and referrals Monitor and process referral management worklists (e.g., Genesis Work Lists) to ensure timely consult processing Communicate referral status to patients, including benefit counseling and advocacy resources as needed Reschedule or redirect patients within 3 days when referrals are disapproved or invalid, advising on other care options and Line-of-Duty issues Receive and enter ROFR referrals in MHS-GENESIS from Military Contractor Support Centers (MCSC) portals for assigned specialties/product lines, adhering to all timelines and business rules Verify patient eligibility and update demographics in MHS-GENESIS Document patient interactions, especially when appointments are refused, and coordinate with Beneficiary Counselor and Assistance Coordinator as appropriate Coordinate with product line nurses and clinics for special accommodations Interface with MCSC and multidisciplinary teams to ensure referral appropriateness Submit referrals to non-network providers for TRICARE Service Center medical necessity reviews Monitor referral management voicemail and return patient calls within established guidelines Provide External Provider Referral Online (EPRO) information as requested Close unused referrals following DHA IPM and NCR Medical Directorate policies, notifying ordering providers accordingly Orient and train new IRMAC staff on referral processes and timelines Perform other duties as assigned Zimmerman Associates, Inc. is an
equal opportunity employer . We comply with Federal and State Equal Opportunity laws and consider qualified applicants without regard to race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, veteran status, or any other protected status. #INDSPN
#J-18808-Ljbffr
is seeking to hire multiple
Referral Management (Non-Nurse) Reviewers
to support our contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Region’s premier authority for appointment coordination and referral management services for beneficiaries within the Defense Health Network. Pay Rate:
$23.56 per hour plus $4.93 Health & Wellness Fringe Role and Responsibilities:
Referral Management (Non-Nurse) Reviewers will facilitate centralized product line and specialty referrals for Active-Duty Service Members and TRICARE Prime beneficiaries enrolled at Military Treatment Facilities (MTFs) within the National Capital Region. This is an
onsite opportunity Qualifications / Skills / Experience:
Minimum of an
Associate’s degree
At least
2 years of experience
in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance Referral
U.S. Citizenship required, with the ability to obtain a Public Trust Clearance
Knowledge of medical care criteria such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs), or other evidence-based Military Health
System (MHS) guidelines
Familiarity with medical terminology and ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, and release of medical information protocols
Excellent communication and interpersonal skills
Strong customer service orientation
Understanding of Access to Care Standards within the Direct Care System
Attention to detail, including correct use of deferral codes
Strong organizational skills with ability to prioritize tasks and manage time effectively
Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Access, Outlook) and internet navigation
Essential Tasks:
Review and process referrals for administrative and clinical completeness and appropriateness, completing disposition within 24 hours of referral date Collaborate with appointing centers, case managers, product line nurses, providers, clinics, managed care contractors, and other healthcare team members to ensure appropriate use of Direct Care and civilian network resources Ensure patients are scheduled with the right provider, at the right time and place Review compliance with Specialty Referral Guidelines (SRGs) per IRMAC protocols Complete and return Clear Legible Reports (CLR) to ordering civilian providers within required Return of Favorable Response (ROFR) timelines Manage telephone, written, and electronic communications regarding specialty appointments and referrals Monitor and process referral management worklists (e.g., Genesis Work Lists) to ensure timely consult processing Communicate referral status to patients, including benefit counseling and advocacy resources as needed Reschedule or redirect patients within 3 days when referrals are disapproved or invalid, advising on other care options and Line-of-Duty issues Receive and enter ROFR referrals in MHS-GENESIS from Military Contractor Support Centers (MCSC) portals for assigned specialties/product lines, adhering to all timelines and business rules Verify patient eligibility and update demographics in MHS-GENESIS Document patient interactions, especially when appointments are refused, and coordinate with Beneficiary Counselor and Assistance Coordinator as appropriate Coordinate with product line nurses and clinics for special accommodations Interface with MCSC and multidisciplinary teams to ensure referral appropriateness Submit referrals to non-network providers for TRICARE Service Center medical necessity reviews Monitor referral management voicemail and return patient calls within established guidelines Provide External Provider Referral Online (EPRO) information as requested Close unused referrals following DHA IPM and NCR Medical Directorate policies, notifying ordering providers accordingly Orient and train new IRMAC staff on referral processes and timelines Perform other duties as assigned Zimmerman Associates, Inc. is an
equal opportunity employer . We comply with Federal and State Equal Opportunity laws and consider qualified applicants without regard to race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, veteran status, or any other protected status. #INDSPN
#J-18808-Ljbffr