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Gastrointrology exp preferred, the patients they are booking are for GI procedures

Referral Background and processing

Booking appointments in the Navigation center,

Epic preferred

Reviews referral information from clinicians for pertinent information regarding tests, consultations, and procedures. Verifies demographics and insurance information. Work is highly complex and detail oriented, involving frequent contact with a range of internal and external contacts as well as the need to understand terms and processes of multiple payers.

Reviews referral information from work queue for pertinent information regarding referral requests.

Reviews each external referral for opportunity to convert to internal referral and reviews options with patients. Redirects patients with managed care products appropriately ensuring clinical handoff is safe using expertise of specialty nurses. Ensures adequate information is obtained and relayed when care is moved.

Explains insurance benefits and options to patients. Explains denials to patients. Keeps patient informed of status of all referrals (approved and denied). Notifies patients of scheduled appointments and confirms appointment by mail including confirmed location and map of destination. Informs patient of any preparation that must be completed prior to the appointment. Contacts patient if insurance coverage issues arise during the referral process so that patient can work directly with the insurance company.

Promotes the Atrius Health System of Care by highlighting internal providers and their expertise.

As needed, places orders to start the referral process for the PCP on behalf of patients who have booked appointments and call for the referral. Researches the visit notes to determine if a referral was intended as well as processing referrals for follow-up or annual visits that require a referral.

Schedules patients for tests, consultations, services and procedures with other departments, local private offices, and/or outside vendors/providers.

Answers phone calls, faxed requests and other inquires relating to referrals and communicates with the physicians and clinicians to acquire authorization or to inform them of patient issues or clinical paperwork needed.

Research questions/concerns from patients regarding bills and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process. Refers patients to appropriate staff (e.g., patient account representatives) for billing issues related to insurance benefits and services covered under the benefits plan.

Works in collaboration with the person designated as the Practice’s Benefits Coordinator to maintain cost control, ensure that services provided are within benefit plan guidelines, and that necessary policies and procedures are followed when dealing with non-preferred providers/vendors. May coordinate second opinion requests.

Works with supervisors to ensure patients are receiving timely responses and detailed answers to their complex questions.

Research questions/concerns from patients regarding billing and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process.

Receives escalated issues and stat same day calls; determine appropriate action and/or works with clinical team for decision.

Effectively deescalates issues with upset patients and practices. Uses advanced listening techniques to understand the issue and give patients options as they are available. Escalates to supervisors only as needed.

Supports roles within the Navigator. Trains and teaches as needed.

Participates in problem solving activities, focusing on productivity and quality. Works with supervisors to ensure continuous improvement of the department.

If needed, contacts appropriate parties to obtain referral authorizations and verify coverage (e.g., the Authorization Services Unit (ASU), National Imaging Associates (NIA) or individual insurance companies). Certain departments may also need to contact additional outside agencies for approval (e.g., American Imaging Management or Med Solutions).