We offer remote work opportunities (AK, AR, AZ, *CO, FL, *HI, IA, ID, *IL, KS, LA, MD, *MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
Serves as a dedicated point of contact for providers for referral and authorization processes and issues. Responsible for researching referral requests and ensuring provider offices have the necessary authorizations to treat beneficiaries. May also perform non-routine, specialty processing as needed.
Education & Experience
Required:
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• High School Diploma or G.E.D.
• Demonstrated proficiency and experience in all referral and authorization processes
• Proficient in Care Radius, DOMA and Patient Information Management System (PIMS) Experience with Microsoft Office
Preferred:
• Experience researching referral and authorization issues in Care Radius, DOMA and PIMS
• Knowledge of medical terminology obtained through medical assistant certification or experience interpreting and applying ICD and CPT codes
• Managed Care experience
• TRICARE experience
• Veteran or military spouse or military affiliated
Key Responsibilities
• Performs extended provider searches when the referral specialist, contact center or MTF isn’t able to locate the requested provider/specialty needed. .
• Shares and collaborates with internal partners to resolve provider referral and authorization issues.
• Identifies potential discrepancies in the medical management system to assure quality compliance.
• Consistently meet department productivity and performance metrics.
• Follows HIPAA compliance and TriWest confidentially guidelines.
• Resolves issues to complete care request.
• Supports systems and process improvements and development of procedures and training documents.
• Assists in producing trend reports to improve workflow efficiency and system functions to recommend possible solutions to management.
• Assists with resolving data quality issues by identifying, documenting, and communicating quality issues.
• Resolve process issues to ensure high quality service levels throughout TriWest.
• Assesses electronic documents to ensure appropriate entry into the medical management system.
• Works with standard coding systems including standard medical taxonomy, ICD-10, CPT and HCPCS codes.
• Processes authorization requests and referral requests in the on-line medical management system as needed.
• Communicates with other departments, medical providers, and beneficiaries to clarify documentation prior to processing.
• Performs other duties as assigned.
• Regular and reliable attendance is required.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.
Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.
Technical Skills: Knowledge of TRICARE and the Military Health System programs; ability to use CHCS booking procedures, ATC standards and established clinic capability/booking protocols.
Working Conditions
Working Conditions:
• Ability to cover any work shift
• Ability to work overtime, if needed
• Onsite: Works within a standard office environment
• Remote: Private and secure workspace and workstation with high speed internet is required
• Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone