Referral Management Reviewers (Bethesda, MD)

Overview

Team Ivyhill is currently seeking to hire Referral Management (Non-Nurse) Reviewers to support its contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Regions' premier coordinating authority for appointing and referral management services for beneficiaries in the Defense Health Network. This is an onsite employment opportunity. Base pay range : $47,000.00/yr Responsibilities

Perform referral review duties, seeking guidance from the product line nurse(s) and other members of the healthcare team and MTF points of contact as necessary. Review all referrals for administrative, clinical completeness and appropriateness, and disposition the referral within 24 hours from the date the referral was written. Collaborates with appointing center, case managers, product line nurses, providers, clinics, managed care support contractor liaison and other members of the healthcare team as needed to ensure proper use of Direct Care system and civilian network resources, as well as to ensure that patients are booked at the right time, with the right provider, at the right place. Review Specialty Referral Guideline (SRG) compliance for disposition per IRMAC guidelines. Complete and return Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines. Receive and place telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitor and process referral management Genesis Work Lists to ensure consults are being processed within the established guidelines. Advise patients of their referral status, provide references for benefit counseling assistance and/or patient advocacy, reschedule/instruct patients of other health care options within 3 days of notification of disapproved referral or invalid referral, and advise on Line-of-Duty issues as it relates to referral management. Receive and enter ROFR referrals in MHS-GENESIS from the MCSC's portal for assigned specialties/product lines. Adhere to defined timelines for response established by MHS and IRMAC SOPs. Identify and resolve ROFR issues in accordance with NCR Business Rules. Report concerns related to the ROFR referral process to the team lead as needed. Verify patients' eligibility in MHS-GENESIS and update demographic information when needed. Document in MHS-GENESIS, explaining appropriate options to patients when they refuse appointments (e.g., point of service, TRICARE Select, be connected to Beneficiary Counselor and Assistance Coordinator). Contact the product line nurse/clinic when appropriate for accommodation of highly valuable cases. Interface with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals. Submit referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review. Routinely monitor referral management voicemail to ensure patient calls are returned within the guidelines established. Provide information about EPRO to requestors outside the NCR requesting care within the NCR. Close unused referrals as directed by DHA IPM, NCR MD policies and notify the ordering provider accordingly. Orient and train new IRMAC staff in the referral processes and timelines. Other duties as assigned. Qualifications / Requirements

Requirements Associate's Degree (minimum) and a minimum of 2 years of experience in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance Referral. Be a U.S. Citizen. Have knowledge and ability to interpret and apply medical care criteria, such as InterQual, Milliman Ambulatory Care Guidelines, SRGs, or other evidence-based guidelines identified by the Military Health System (MHS). Have knowledge of medical terminology with the ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, and release of medical information. Have effective communication and people skills. Have demonstrated ability to provide superior customer service. Have knowledge and understanding of Access to Care Standards within the Direct Care System. Be able to pay strict attention to detail and the appropriate use of deferral codes. Have excellent organizational skills, including time management, prioritization, goal setting, and plan implementation. Have working knowledge of Microsoft Office applications (Word, Excel, PowerPoint, Access, Outlook) and the Internet. Benefits

Ivyhill has a competitive benefits program which includes medical, dental and vision; Life and AD&D insurance; Short- and Long-Term Disability; supplemental Life insurance and a 401(k) Plan. Employment details

Seniority level: Associate Employment type: Full-time Job function: Health Care Provider Industries: IT Services and IT Consulting

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