Referral Processor II

Company Name:
Kaiser Permanente
Performs a variety of procedures to process complex outside medical referrals, functions as a liaison, and works independently. Makes members/patients and their needs a primary focus of one's actions; develops and sustains productive member/patient relationships. Actively seeks information to understand member/patient circumstances, problems, expectations, and needs. Builds rapport and cooperative relationship with members/patients. Considers how actions or plans will affect members; responds quickly to meet member/patient needs and resolves problems.
Essential Functions:
- Processes complex outside medical referrals received electronically: reviews referral for completeness and requests additional information as necessary; verifies member eligibility, ensures appropriate review nurse approval is obtained when necessary, codes diagnoses and procedures, enters information into system, notifies member of referral authorization and schedules appointments as needed. Answers a variety of telephone inquiries received from patients and medical providers regarding benefit coverage, policies, procedures and services, using a computer terminal and departmental reference materials. Informs patients and providers of referral process and limitations, associated charges, appointments, and member responsibilities. Determines appropriate party to be billed for services (e.g. Worker's Compensation, COB, non-covered benefits, etc.) and documents in the system. Researches and prints from automated medical records system medical records, x-rays and/or laboratory work to go to outside provider when appropriate.
- Functions as a liaison between vendors, physicians and members with regard to questions and problems with referrals, including keeping outside providers updated with pertinent information. Researches each referral to ensure service requested is a benefit for the member. Gathers data on interregional members verifies eligibility status by contacting member's home region. Performs other duties as assigned by management.
Basic Qualifications:
- Four (4) years of previous experience, which includes two (2) years of experience working in a private doctor's office doing front and back office duties plus two (2) years of previous experience processing electronic or on-line medical referrals.
- High school graduation or equivalent.
License, Certification, Registration
- N/A
Additional Requirements:
- Working knowledge of Medicare, Medicaid, work comp and no fault regulations.
- Demonstrated ability to read/interpret provider orders and to apply medical coding procedures using CPT-4 and ICD-9. Medical terminology required.
- Demonstrated customer service skills, customer focus abilities and the ability to understand Kaiser Permanente customer needs.
- Strong customer service skills and the ability to multitask.
- Testing Required: Typing speed of 35 w.p.m. Experience using 10-key by touch.
Preferred Qualifications:
- N/A
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.

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