Referral Specialist III/Patient Access – Pre & Prior Authorizations – Appeals – Insurance – Paragon Infusion

Referral Specialist III/Patient Access – Pre & Prior Authorizations – Appeals – Insurance – Paragon Infusion

Requirements

• Requires a HS diploma or equivalent and a minimum of 3 years of experience in customer service experience in healthcare related setting; or any combination of education and experience which would provide an equivalent background.

Responsibilities

• Providing technical guidance to Referral Specialists assist callers with issues concerning contract and benefit eligibility for requested continuing pre-certification and prior authorization of inpatient and outpatient services outside of initial authorized set.
• Handling escalated and unresolved calls from less experienced team members.
• Training and/or Precepting Associates to deliver and enhance the ability to serve callers.
• Auditing the performance of Referral Specialists, assisting in the review of audit appeals and documenting audit statistics.
• Acts as a SME, ability beyond intake calls that include verifying eligibility and benefits for medical and pharmacy payers through multiple methods for specialty chronic and acute therapy services.
• Acts as liaison between patients, healthcare providers, infusion centers, pharmacy, and billing department to address issues.
• Ability to review and interpret clinical records to ensure patient meets medical policy guidelines for coverage, for completeness, and performs follow-up for additional information if necessary.
• Ability to initiate pre-determination, prior authorizations, and appeals for denials based on payer policy.
• Ability to read and interpret payer contracts, and payer policies to effectively manage referrals and mitigate risk of accounts receivable.
• Maintain knowledge of therapies serviced by Paragon, at minimum, therapy and diagnosis correlation and patient information required.
• Contacts physician offices as needed to obtain demographic information or related data.
• Manage referrals, documents communications, actions, and other data in the system.

Preferred Qualifications

• 4 years of experience in healthcare reimbursement, billing, or patient access, with specific experience in infusion therapy strongly preferred.
• Advanced knowledge of HCPCS, NDC, CPT, and ICD-10 coding for referral management is strongly preferred.
• Advanced knowledge of Medicare Local Coverage Determination is strongly preferred.
• Knowledge of insurance verification, pre-authorization, and claims submission process is strongly preferred.
• Strong mathematical, analytical, and problem-solving skills.
• Proficiency in computer skills, including electronic health record systems and Microsoft Office suite.
• An associate or bachelor’s degree is preferred, but not required.
• Ability to work independently and collaboratively.
• Ability to maintain professionalism and confidentiality.