Referral Specialist

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI \& WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Ensures accuracy and completion of authorization data from customer information, medical records, referral/authorization forms, Military Treatment Facility electronic transmission and other documents into medical management system. Examine and evaluate document contents to ensure accuracy and to correct inconsistencies. Duties may be performed in a virtual environment. Maintains confidentiality of TriWest beneficiaries' health information. **Education \& Experience** **Required:** * U.S. Citizenship * Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation * High School Diploma or G.E.D. * 1 \+ year experience in health care operations performing data entry or customer service * Experience with Microsoft Office **Preferred:** * Referral and authorization processing experience * Knowledge of medical terminology obtained through medical assistant certification or experience interpreting and applying ICD and CPT codes * Managed Care experience * TRICARE experience * Veteran or military spouse or military affiliated **Key Responsibilities** * Assesses tasks for authorization/referral request to ensure accurate entry into the medical management system. * Identifies potential discrepancies in the medical management system to assure quality compliance. * Consistently meets department productivity and performance metrics. * Follow HIPAA compliance and TriWest confidentially guidelines. * Refers beneficiaries to network providers. * Resolves issues to complete care request. * Reads and comprehends diagnosis, procedures and requested service on incoming care requests. * Assists with resolving data quality issues by identifying, documenting, and communicating quality issues * Resolve process issues to ensure high quality service levels throughout TriWest. Seeks advice and escalates issues or problems as warranted. * Processes referrals for Behavioral Health, Specialty Care, Durable Medical Equipment, Inpatient Admissions, Military Treatment Facilities, and Urgent referral and authorization requests. * Assesses electronic documents to ensure appropriate entry into the medical management system. * Works with standard coding systems including: standard medical taxonomy, ICD\-10, CPT and HCPCS codes. * Verifies beneficiary eligibility and ensures appropriate referral procedures are followed for the various types of TRICARE beneficiaries. * Ensures procedures are followed for referrals based on beneficiary eligibility type, geographical location, and on the provider's request. * Processe