Quality and Referral Specialist
Quality and Referral Specialist
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Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Manage all facets of the patient referral and prior authorization include but are not limited to obtaining pre-certification or prior-authorizations scheduling the visit with specialist or outpatient services completion of documentation with the electronic medical record (EMR) and communicating referral information to referring offices and to the patient.
Provides assistance and support in the coordination of performance and quality improvement activities by data collection and reporting. Collaborates and communicates with the main stakeholders in a clear and consistent manner. Provides tools and resources to all department and services on best practices related to patient experience. Supports Privacy Officer in all HIPAA and Privacy regulations and education.
Key Accountability
- Referral Processes to include:
- Coordinates appointments and relays authorization information to scheduling staff of specialist or outpatient service offices as requested.
- Completes appropriate forms or requisitions needed for referrals or testing including appropriate CPT/ICD-10 coding.
- Provides appropriate and timely documentation in the patients EMR using standardized workflows and processes.
- Notifies patient of appointment details via telephone MyChart and letter.
- Ensure patients are informed of scheduled tests/procedures.
- Reinforces instructions and explanations of tests/procedures to patients per protocol.
- and imaging for patients.
- Coordinates pre-certs and authorization processes with scheduling staff at referral sight so appointments can be made in timely manner.
- Obtains any and all pertinent clinic health information from provider clinical staff and/or EMR to process authorizations referrals and pre-certifications.
- Verifies demographic information including insurance when scheduling and/or obtaining pre-certifications.
- Monitors outstanding authorization requests and initiates follow-up of outstanding authorizations in a timely manner.
- Maintains current knowledge of payer specific requirements of prior authorizations by attending virtual workshops researching and reading newsletters.
- Acts as a liaison between Clarke County Hospital and all referral sources.
- Utilizes exemplary customer service skills with every patient interaction
- Meet specified deadlines as required for continued patient satisfaction.
- Demonstrate a professional image in dealing with the public patients families and payors.
- Maintain regular and consistent attendance at work.
Key Accountability
- Quality Specialist to include:
- Adheres to hospital and department policies and procedures as established.
- Observes opportunities for improvement formulates ideas and communicates those ideas with appropriate managers and Quality Improvement manager.
- Completes quality audits as indicated. Runs reports and completes charts for patient experience and quality department.
- Supports and assists with project work including but not limited to: HIPAA compliance and audits patient experience initiatives and other projects as identified by the Quality Improvement Manager.
- Maintains strict confidentiality of data related to patients and physicians.
- Patient Experience liaison between NRC UnityPoint Health Des Moines and Clarke County Hospital. Provides Leadership Team with patient satisfaction data.
- Serves as a member of the Patient Experience Committee and other teams/committees as assigned.
Basic Clarke County Hospital (CCH) Performance Criteria
- Demonstrates Clarke County Hospital Standards of Behaviors as well as adheres to hospital policies and procedures and safety guidelines.
- Demonstrates ability to meet business needs of department with regular reliable attendance.
- Employee maintains current licenses and/or certifications required for the position.
- Practices and reflects knowledge of HIPAA DIA DNV OSHA and other federal/state regulatory agencies guiding healthcare.
- Completes all annual education and competency requirements within the calendar year.
- Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.
Qualifications
Education: High School Diploma. Preferred: College Degree
Experience: Medical background sufficient enough to review patient data and abstract information needed to perform job duties. Preferred: Two (2) years of experience in clinical setting.
License(s)/Certification(s): Valid drivers license when driving any vehicle for work-related reasons.
Knowledge/Skills/Abilities: Good communication skills to work with physicians outside agencies and hospital personnel. Basic computer and typing skills ability. Use of Excel Powerpoint and Word.
Shifts/Schedule: Monday-Friday; 40 hours per week - Normal business hours/ Remote
Required Experience:
Unclear Seniority
Employment Type
Full-Time
