Hybrid Referral Specialist I – Patient Access, Pre & Prior Authorizations, Appeals, Insurance

at Elevance Health

• Job title: Referral Specialist I – Patient Access, Pre & Prior Authorizations, Appeals, Insurance
• Job type: Full Time
• Experience level: Junior
• Salary: Not specified
• Degree requirement: High School Diploma
• Location requirements: Hybrid, Plano, United States

About the role

• Referral Specialist I providing support to clinical team at Elevance Health. Facilitating administrative components of clinical referrals with insurance and patient interactions in a hybrid environment.

Responsibilities

• Provide support to a clinical team to facilitate the administrative components of clinical referrals
• Verify eligibility and benefits for medical and pharmacy payers through multiple methods for specialty chronic and acute therapy services
• Act as liaison between patients, healthcare providers, infusion centers, pharmacy, and billing department to address issues
• Review and interpret clinical records to ensure the patient meets medical policy guidelines for coverage
• Initiate pre-determination, prior authorizations, and appeals for denials based on payer policy
• 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
• Contact physician offices as needed to obtain demographic information or related data
• Manage referrals, documents communications, actions, and other data in the system

Requirements

• Requires HS diploma or GED
• Minimum of 1 year of experience in a high-volume, interactive customer service or call center environment
• Preferred 1 year of experience in healthcare reimbursement, billing, or patient access, with specific experience in infusion therapy
• Advanced knowledge of HCPCS, NDC, CPT, and ICD-10 coding for referral management
• Advanced knowledge of Medicare Local Coverage Determination
• Knowledge of insurance verification, pre-authorization, and claims submission process
• 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

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical benefits
• dental benefits
• vision benefits
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources