Kaiser Permanente
Referral Coordinator
Responsible for initiating and completing internal/external referral requests received through phone, fax, health connect, and on-line affiliate link. Initiates and completes data entry utilizing a standardized documentation template along with established policies and procedures. Provides initial review of benefits and eligibility for services requiring authorization. Assigns or ensures correct ICD-10, HCPCS, and CPT codes have been entered. Responsible for notifying members regarding referral/authorization orders, eligibility/benefit questions, and scheduling appointments for external referral consultations, tests, and/or procedures. Supports the daily activities of the QRM/Post-Acute Regional Review Team. Essential responsibilities include initiating and completing internal/external, pre-certification referral requests received; providing data entry on all authorization requests based on a documentation standard template with established policies and procedures for the purpose of clinical review; performing data entry and approval of all pre-certification notification only requests (no clinical review) utilizing established criteria and guidelines and documenting according to standard templates and with established policies and procedures; reviewing eligibility and benefits of the member, utilizing established criteria and guidelines and coordinating with member services and benefits department; assigning appropriate diagnosis and procedure codes following coding guidelines for ICD-10, CPT, and HCPCS codes for all (pre-certification) referral requests; aiding specialists or primary care practitioners and office staff on coding and target review questions; maintaining current knowledge of both coding and targeted review items to ensure that the right requests are initiated and sent to the correct specialty review per contract and benefit guidelines and adheres to time frame specified by Kaiser Permanente standards; ensuring coding is completed correctly on all requests to meet all regulatory guidelines and audit standards which will result in compliance and correct reimbursement; once data entry is complete, a copy of the referral form is sent to the consultant via the member or fax; assisting and educating members by answering questions regarding referral and authorization process; assisting and educating the external consultants with questions and concerns with the referral process in the medical office; maintaining effective interaction/communication with physicians and their staff as necessary to gather information for referrals as needed; responsible for the support of operational activities for the QRM review team; assisting the referral leadership with preparation and running reports and other duties as assigned; forwarding authorization requests (live caller or documented record) requiring a clinical review to the appropriate review staff/team; providing verbal notification in accordance to policy and procedure for members and providers with respect to the outcome of their requested service; providing information to the member regarding the location of consultants office, address, and phone number; managing incoming right fax physician requests by sorting, entering into the authorization system, and assigning to the correct specialty reviewer; remaining knowledgeable of contract benefits, eligibility guidelines, and current state and federal regulations that affect managed care and utilization management; interacting with physicians, staff, and team members as necessary to gather required information needed for clinical reviews; maintaining excellent customer service and professionalism with providers, members, and team members always; maintaining department productivity standards and accuracy in data entry; maintaining effective interaction/communication and working relationships with members of the medical staff, complex case managers, regional review RNs, and other QRM staff to facilitate the general review process; working cross-functionally with other departments such as the Kaiser Permanente medical offices, customer services, claims, provider relations, appeals, and risk management, in striving to meet organizational goals and objectives; investigating, identifying, and reporting problems and inefficiencies in existing systems and recommending changes when appropriate to the referral leadership; knowledgeable and compliant with regional and QRM department-specific personnel policies and procedures; developing and maintaining an awareness of how to report compliance issues and concerns; identifying the need for social services intervention and referring the member to KP social workers as appropriate; maintaining complete and accurate data entry for all internal/external, pre-certification referrals into Epic Tapestry based on policies and procedures. Basic qualifications include minimum four (4) years of previous experience in the healthcare industry and minimum six (6) months experience receiving and processing referral requests. Education required is a high school diploma or general education development (GED). License, certification, registration required is certified coding specialist within 6 months of hire OR certified professional coder within 6 months of hire OR certified coding specialist - physician based within 6 months of hire OR certified outpatient coder within 6 months of hire. Additional requirements include demonstrated customer service skills, customer focus abilities, and the ability to understand Kaiser Permanente customer needs. Demonstrated planning and time management skills, including the ability to handle multiple tasks at one time. Preferred qualifications include Epic Tapestry experience, minimum one (1) year working with CPT and ICD-10 coding knowledge, and medical terminology certificate.
Responsible for initiating and completing internal/external referral requests received through phone, fax, health connect, and on-line affiliate link. Initiates and completes data entry utilizing a standardized documentation template along with established policies and procedures. Provides initial review of benefits and eligibility for services requiring authorization. Assigns or ensures correct ICD-10, HCPCS, and CPT codes have been entered. Responsible for notifying members regarding referral/authorization orders, eligibility/benefit questions, and scheduling appointments for external referral consultations, tests, and/or procedures. Supports the daily activities of the QRM/Post-Acute Regional Review Team. Essential responsibilities include initiating and completing internal/external, pre-certification referral requests received; providing data entry on all authorization requests based on a documentation standard template with established policies and procedures for the purpose of clinical review; performing data entry and approval of all pre-certification notification only requests (no clinical review) utilizing established criteria and guidelines and documenting according to standard templates and with established policies and procedures; reviewing eligibility and benefits of the member, utilizing established criteria and guidelines and coordinating with member services and benefits department; assigning appropriate diagnosis and procedure codes following coding guidelines for ICD-10, CPT, and HCPCS codes for all (pre-certification) referral requests; aiding specialists or primary care practitioners and office staff on coding and target review questions; maintaining current knowledge of both coding and targeted review items to ensure that the right requests are initiated and sent to the correct specialty review per contract and benefit guidelines and adheres to time frame specified by Kaiser Permanente standards; ensuring coding is completed correctly on all requests to meet all regulatory guidelines and audit standards which will result in compliance and correct reimbursement; once data entry is complete, a copy of the referral form is sent to the consultant via the member or fax; assisting and educating members by answering questions regarding referral and authorization process; assisting and educating the external consultants with questions and concerns with the referral process in the medical office; maintaining effective interaction/communication with physicians and their staff as necessary to gather information for referrals as needed; responsible for the support of operational activities for the QRM review team; assisting the referral leadership with preparation and running reports and other duties as assigned; forwarding authorization requests (live caller or documented record) requiring a clinical review to the appropriate review staff/team; providing verbal notification in accordance to policy and procedure for members and providers with respect to the outcome of their requested service; providing information to the member regarding the location of consultants office, address, and phone number; managing incoming right fax physician requests by sorting, entering into the authorization system, and assigning to the correct specialty reviewer; remaining knowledgeable of contract benefits, eligibility guidelines, and current state and federal regulations that affect managed care and utilization management; interacting with physicians, staff, and team members as necessary to gather required information needed for clinical reviews; maintaining excellent customer service and professionalism with providers, members, and team members always; maintaining department productivity standards and accuracy in data entry; maintaining effective interaction/communication and working relationships with members of the medical staff, complex case managers, regional review RNs, and other QRM staff to facilitate the general review process; working cross-functionally with other departments such as the Kaiser Permanente medical offices, customer services, claims, provider relations, appeals, and risk management, in striving to meet organizational goals and objectives; investigating, identifying, and reporting problems and inefficiencies in existing systems and recommending changes when appropriate to the referral leadership; knowledgeable and compliant with regional and QRM department-specific personnel policies and procedures; developing and maintaining an awareness of how to report compliance issues and concerns; identifying the need for social services intervention and referring the member to KP social workers as appropriate; maintaining complete and accurate data entry for all internal/external, pre-certification referrals into Epic Tapestry based on policies and procedures. Basic qualifications include minimum four (4) years of previous experience in the healthcare industry and minimum six (6) months experience receiving and processing referral requests. Education required is a high school diploma or general education development (GED). License, certification, registration required is certified coding specialist within 6 months of hire OR certified professional coder within 6 months of hire OR certified coding specialist - physician based within 6 months of hire OR certified outpatient coder within 6 months of hire. Additional requirements include demonstrated customer service skills, customer focus abilities, and the ability to understand Kaiser Permanente customer needs. Demonstrated planning and time management skills, including the ability to handle multiple tasks at one time. Preferred qualifications include Epic Tapestry experience, minimum one (1) year working with CPT and ICD-10 coding knowledge, and medical terminology certificate.