Authorization referral coordinator - Robbins - job 1197129

Date: 09/12/2021

City: Robbins, Illinois

Employment type: Full-time

Employment Type:
Full time


Note: This position is located at the Westmont Office

As part of Loyola Medicine, the Loyola Physicians Partners (LPP) Health Plan manages delegated activities of the LPP HMO. The ideal candidate will have experience it managing referrals at an insurance company or MCO.

Reporting to the Manager of Utilization Management and working under general supervision, manages utilization resources and quality of healthcare services through performing initial intake, support and processing of pre-certification requests for eligible members received via portal, EHR, or telephonic, for outpatient and inpatient elective services specified on the preauthorization required list. Utilizes health plan scope of benefits, medical policies, organizational approved medical necessity criteria and home

network capabilities to determine if a request meets the guidelines for approval. Approves services under the supervision of the clinical team per protocol. Refers requests to the nurse reviewer or medical director if criteria or guidelines not met.

Retrieves information from portal, EHR, fax or telephonically and checks

for completeness and accuracy. Verifies member eligibility, requested

provider/service network status and the inclusion of clinical

documentation supporting the request. Contacts provider phone/fax

when further information or corrections are needed and monitors system

for receipt of this information. Assists providers in finding where services

are available within the home and preferred networks.

Determines whether requested service is in the health plan's scope of

benefits. Sends requests for benefit determination when required.

Identifies if out of network services requested can be done in network

and refers appropriately. Evaluate whether the request matches medical

policies, medical necessity criteria and organizational protocols. Under

nursing oversight utilizes appropriate resources such as case

management coordinators, medical director, primary care physicians,

protocols and criteria to assist with making sound decisions within the

benefit plan. Escalates to next level when guidelines are not met. Uses

UM and EHR databases and software as indicated.

Responds to phone inquiries from HMO providers and members. Refers

them to appropriate resources. Answers UM related calls from providers,

members and external customers with professionalism and courtesy in a

timely manner. Communicates the approval/denial of pre-authorization

requests to the PCP and consulting physicians. Sends communications as

directed. Refers cases to care coordinators as indicated. Assists in

developing innovative practices, policies and procedures for the

utilization Management department.

Demonstrates leadership behaviors that enhance and support team

functions. Commits to ongoing education and training. Maintains

competencies and participates in continuing education for self and

development of colleagues.

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.

How to apply:

This job is expired.