As a not-for-profit organization, Partners HealthCare is committed to supporting patient care, research, teaching, and service to the community by leading innovation across our system. Founded by Brigham and Women's Hospital and Massachusetts General Hospital, Partners HealthCare supports a complete continuum of care including community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities. Several of our hospitals are teaching affiliates of Harvard Medical School, and our system is a national leader in biomedical research.
We're focused on a people-first culture for our system's patients and our professional family. That's why we provide our employees with more ways to achieve their potential. Partners HealthCare is committed to aligning our employees' personal aspirations with projects that match their capabilities and creating a culture that empowers our managers to become trusted mentors. We support each member of our team to own their personal development-and we recognize success at every step.
Our employees use the Partners HealthCare values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration.
Under general direction of the Manager, the incumbent is primarily responsible for working collaboratively with primary care Practices, specialty care Practices, primary care physicians, referring physicians, and patients to ensure that required referrals are obtained and appropriately recorded in the relevant practice management systems prior to scheduled patient visits. The Referral Services Representative will communicate with patients, physicians and payor representatives as necessary in order to accomplish this, utilizing available management reports to follow-up on unresolved issues and denied claims. The Referral Services Representative is responsible for performing various administrative and clerical duties required to support these functions and, on an as-needed basis, may be required to perform other tasks.
Principal Duties and Responsibilities
Primarily responsible for working collaboratively with Partners practices to obtain referrals for specialty services prior to scheduled visits by effectively communicating with payers to submit, track, follow-up and obtain referrals, in a timely manner via websites, software, fax and telephone. Duties include running and working Ontrac worklists, EPIC work queues and checking information in EPIC to determine if a valid referral for internal, external and/or incoming visits exists. If a valid referral is in EPIC, the incumbent will be responsible for linking the referral to the appropriate visit(s). For visits without a valid referral in the EPIC, the incumbent will use various payer technologies to obtain referral and authorization numbers for Partners primary care practices and for specialty visits by contacting external PCPs to obtain referral numbers. Follow-up requires coding the work in Ontrac and entering information into EPIC.
Responsible for documenting and tracking the number of referrals that are tickled (deferred), generated and obtained. Following-up with practices who do not immediately issue a referral, noting the reason for the delay and documenting when referrals are denied. Interfacing with practices and patients to report referral information. Complying with Patient Service Center standards for productivity, accuracy, quality and customer service.
Responsible for verifying and updating patient registration information, including insurance, demographic and patient data needed to perform referral management functions. Work collaboratively with the Registration Department to resolve registration issues. Responds to questions regarding open accounts or managed care/insurance issues.
Interfacing with patients will be necessary when information required to obtain an insurance referral cannot be completed. This may include working with a patient to: 1) to confirm and/or facilitate PCP assignment, 2) resolve insurance discrepancies, 3) re-verify insurance information with the patient, correcting information in Partners' systems and then resubmitting referral requests to the insurance company.
Responsible for communicating benefit plan information to patients when necessary and following-up with insurance companies and/or patients to ensure information has been updated with payers.
Works with all Partners Support Staff and leadership to prioritize and facilitate referral processes to maintain integrity of service standards.
Develops a clear understanding of the various payor referral and authorization process and requirements for departmental policies and procedures.
Serves as a resource to providers, support staff and patients regarding the referral and authorization process; researches questions thoroughly and assists with interpretation of health plan guidelines.
Receives inquiries from customers, investigates and disseminates information to requestor and wider audiences as appropriate.
Works with Ontrac tool & reporting to review billing rejections and resolve insurance issues to maximize reimbursement. This includes, but is not limited to, obtaining retroactive referral numbers for bills that were denied for no referral.
Works with EPIC work queues to review billing rejections and resolve insurance issues to maximize reimbursement. This includes, but is not limited to, obtaining retroactive referral numbers for bills that were denied for no referral.
Identify need for escalation of issues or problems to appropriate supervisor or manager.
Performs other duties as assigned.
High school diploma or equivalent required. Some college preferred.
Minimum of 3 years preferred, Patient Access Services experience in a hospital or ambulatory setting with knowledge and experience with front end registration and insurance referrals.
An effective team player with strong inter-personal skills.
Demonstrated ability to work and make decisions in a fast paced, high volume work environment.
Proficient with office software packages such as word processing and spreadsheets, including Epic, Huron and any other system the PSC may be utilizing.
Call Center environment experience
The ability to set prioritize and follow through with responsibilities
Ability to exercise appropriate judgment with sensitive and confidential material
The ability to successfully resolve conflict Ability to communicate and interact effectively with all levels of hospital personnel
Ability to maintain confidentiality with regard to all phases of the work
Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements
Ability to concentrate and maintain accuracy in spite of frequent interruptions
Ability to be courteous, tactful, and cooperative throughout the working day
Ability to use judgment in carrying out all phases of the work
Ability to use standard office equipment including computers, photocopy and facsimile machines, and readers/printers
Excellent Customer Service Skills, demonstrated ability to use appropriate judgment, independent thinking and creativity when resolving customer issues.
Partners HealthCare is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.