QA \ UR \ Case Management Jobs


Coord Referral Atlanta, GA


Responsible for completing external referral requests received via Health Connect and On Line Affiliate with appropriate CPT and HCPCS codes and to ensure correct ICD9 codes have been entered. Responsible for coordinating the referral process based on established policies and procedures. Responsible for notifying members regarding referral /authorization orders , eligibility / benefit questions and scheduling appointments for external referral consultations, tests and procedures.

Essential Responsibilities:
- Assigns appropriate CPT procedure and HCPCS codes following coding guidelines for all referral requests and to ensure appropriate ICD-9 codes have been entered on all requests. Provides assistance to TSPMG providers and office staff on coding and targeted review questions. Maintains current knowledge of both coding and targeted review to ensure that the right requests are initiated and sent to review and that proper coding is done on all requests so as to meet all regulatory guidelines and audit standards which will result in proper reimbursement. Responsible for the day to day referral coordination activities as noted below. Complete and accurate data entry for all external referrals into Epic Tapestry based on policy and procedures. Determines eligibility and benefits regarding each referral/authorization and coordinates with membership accounting and customer service. Determines appropriate consultant per specialty type and per contract and benefit guidelines and acts appropriately to time frame specified by Kaiser Permanente physician or consultant (re: routine, expedite, stat). Provides assistance for members by scheduling appointments for external referral consultations, outpatient tests and procedures with our contracted vendors. Provides information to the member regarding location of consultant's office, phone number and the need to bring the referral and clinical information to the consultant's office. Once data entry is complete, a copy of the referral form is sent to the consultant via the member or fax. Assists and educates members by answering questions regarding referral and authorization process. Assists and educates the external consultants with questions and concerns with the referral process in the medical office. Maintains effective interaction/communication with physicians and their staff as necessary to gather information for referrals as needed. Assists the Referral Coordinator Supervisor with running and preparing reports as requested. Remains knowledgeable of contract benefits and current, relevant state and Federal regulations. Builds effective working relationships with physicians/staff, QRM staff, and other departments within the health plan. Identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Referral Coordinator Supervisor. Identifies the need for social service intervention and refers the member to Kaiser Permanent's social workers as appropriate. Maintains member confidentiality. Knowledgeable and compliant with regional personnel policies and procedures. Knowledgeable and compliant with QRM departmental and unit specific policies and procedures. Participates in annual regional and departmental compliance training. Knowledgeable and compliant with Principles of Responsibility. Develops and maintains an awareness of how to report compliance issues and concerns.


Basic Qualifications:
- One (1) year of minimum experience and working knowledge of CPT , ICD-9 coding required.
- Two (2) years of experience in a medical setting, at least one of which should be in managed health care delivery.
- Two (2) years data entry experience.
- Experience with and understanding of benefits and non-benefits.
- Minimum of one (1) year of college.
License, Certification, Registration
- Certificate in medical terminology required.

Additional Requirements:
- Understanding of capitation, fee for service agreements as well as co-pay and COB information.
- Ability to build effective working relationships with physicians and their staff, other QRM staff members, hospitals, vendors, and other departments.
- Ability to handle frequent change.
- Ability to deal with interpersonal conflict with a mature attitude.
- Committed to the organization to do what is necessary to have a successful Referral Management Program.
- Ability to conform to established policies and procedures.

Preferred Qualifications:
- Coding, precertification back ground preferred.
- Certificate in ICD-9 and CPT coding preferred.

Primary Location: Georgia,Atlanta,Regional Office - 10 Piedmont 10 Piedmont Center

Scheduled Hours (1-40): 40

Shift: Day

Working Days: Variable

Schedule: Full-time

Job Type: Standard

Employee Status: Regular

Employee Group: UFCW - Local 1996

Job Level: Entry Level

Job: QA / UR / Case Management

Public Department Name: Quality Resource Management

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.

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