Ivyhill Technologies

Enterprise information management and IT services

Referral Management (Non-Nurse) Reviewers

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeBethesda, MD, USA$47k

About the Job

Requirements

A minimum Associate's Degree and at least 2 years of experience in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance Referral.
Be a U.S. Citizen.
Have the knowledge, skills, and computer literacy to interpret and apply medical care criteria, such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines, or other evidence-based guidelines identified by the Military Health System.
Have knowledge of medical terminology and the ability to learn the Military Health System, VA-DoD Sharing Program, TRICARE, HIPAA, and release of medical information.
Have demonstrated superior customer service skills.
Have demonstrated knowledge and understanding of Access to Care Standards within the Direct Care System.
Pay strict attention to detail and use deferral codes appropriately.
Have organizational skills, including the ability to manage time effectively, prioritize tasks, set goals, and implement plans to achieve those goals.
Have a working knowledge of Microsoft Office products, including Word, Excel, PowerPoint, Access, Outlook, and the Internet.

Responsibilities

Perform referral reviews, seeking guidance from product line nurses, other healthcare team members, and Military Treatment Facility points of contact as needed. Review referrals for administrative and clinical completeness and appropriateness, dispositioning them within 24 hours of the date they were written. Collaborate with the appointing center, case managers, product line nurses, providers, clinics, managed care support contractor liaisons, and other healthcare team members to ensure proper use of direct-care and civilian-network resources and timely booking with the appropriate provider and location.
Review compliance with Specialty Referral Guidelines for disposition according to Integrated Referral Management and Appointing Center guidelines.
Complete and return Clear Legible Reports to the ordering civilian provider within required Right of First Refusal timelines.
Receive and place telephone calls and computer or written correspondence regarding specialty clinic appointments and referrals. Monitor and process referral management Genesis work lists to ensure consults are processed within established guidelines.
Advise patients of referral status, including providing references for benefit counseling assistance or patient advocacy. Reschedule or instruct patients about other healthcare options within three days of notification of a disapproved or invalid referral. Advise patients about Line-of-Duty issues related to referral management.
Receive and enter Right of First Refusal referrals in MHS-GENESIS from the managed care support contractor’s portal for assigned specialties or product lines. Follow response timelines established by MHS and Integrated Referral Management and Appointing Center standard operating procedures. Identify and resolve Right of First Refusal issues under National Capital Region business rules and report concerns to the team lead as needed.
Verify patient eligibility in MHS-GENESIS and update demographic information as needed.
Document in MHS-GENESIS appropriate options for patients who refuse appointments within access-to-care standards, such as point of service, TRICARE Select, or connection to a Beneficiary Counselor and Assistance Coordinator.
Contact the product line nurse or clinic when appropriate to accommodate highly valuable cases.
Interface with the managed care support contractor and multidisciplinary personnel to ensure referral appropriateness. Submit referrals to non-network providers to the TRICARE Service Center for medical necessity and appropriateness review.
Monitor referral management voicemail to ensure patient calls are returned within established guidelines.
Provide information about EPRO to requestors outside the National Capital Region seeking care within the region.
Close unused referrals as directed by Defense Health Agency Integrated Program Management and National Capital Region medical director policies, and notify the ordering provider.
Orient and train new Integrated Referral Management and Appointing Center staff in referral processes and timelines.
Perform other duties as assigned.

Referral Management Reviewers (Bethesda, MD)

Ivyhill Technologies LLC · Bethesda, United States · Full-time · Posted 2024-10-20

Salary: USD 47,000–47,000

Workplace: on_site

Description

Team Ivyhill is currently seeking to hire Referral Management (Non-Nurse) Reviewers to support its contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Regions’ premier coordinating authority for appointing and referral management services for beneficiaries in the Defense Health Network.

Referral Management (Non-Nurse) Reviewers will be responsible for facilitating centralized product line and specialty referrals for Active-Duty Service Members and Tricare Prime beneficiaries enrolled to a Military Treatment Facility (MTF) in the National Capital Region.

This is an onsite employment opportunity.

Duties and Responsibilities

Perform referral review duties, seeking guidance from the product line nurse(s), and other members of the healthcare team and MTF points of contact as necessary. Reviews all referrals for administrative, clinical completeness and appropriateness, dispositioning the referral within 24 hours from the date referral was written. Collaborates with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison and other members of the healthcare team as needed to ensure proper use of Direct Care system and civilian network resources, as well as to ensure that patients are booked at the right time, with the right provider, at the right place.
Review Specialty Referral Guideline (SRG) compliance for disposition per IRMAC guidelines.
Completes and returns Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.
Receives and places telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors and processes referral management Genesis Work Lists to ensure consults are being processed within the established guidelines.
Advises patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy. Reschedule/instruct patients of other health care options within 3 days of notification of disapproved referral or invalid referral. Advises of Line-of-Duty issues as it relates to referral management.
Receives and enters ROFR referrals in MHS-GENESIS from the MCSC’s portal for assigned specialties/product lines. Adheres to the defined timelines for response established by MHS, IRMAC standard operating procedures. Identifies and resolves ROFR issues in accordance with NCR Business Rules. Reports concerns related to the ROFR referral process to team lead as needed.
Completes and returns Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.
Verifies patients' eligibility in MHS-GENESIS. Update demographic information when needed.
Document in MHS-GENESIS, explaining appropriate options to patients when they refuse appointments within access to care (i.e., point of service, Tricare Select, be connected to Beneficiary Counselor and Assistance Coordinator).
Contacts product line nurse/clinic when appropriate for accommodation of highly valuable cases.
Interfaces with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review.
Routinely monitors referral management voicemail to ensure patient calls are returned within the guidelines established.
Provides information about EPRO to requestors outside the NCR requesting care within the NCR.
Closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly.
Orients and trains new IRMAC staff in the referral processes and timelines.
Other duties as assigned.

Requirements

Qualified candidates must have a minimum of an Associate’s Degree and a minimum of 2 years of experience in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance Referral. Additionally, qualified candidates must:

Be a U.S. Citizen.
Have the knowledge, skills, and computer literacy to interpret and apply medical care criteria, such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs) or other evidence-based guidelines identified by the Military Health System (MHS).
Have knowledge of medical terminology with an ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information.
Have effective communication and people skills.
Have demonstrated ability to provide superior customer service skills.
Have demonstrated knowledge and understanding of Access to Care Standards within the Direct Care System.
Be able to pay strict attention to detail and the appropriate use of deferral codes.
Have excellent organizational skills, i.e., ability to manage time effectively, prioritize tasks, set goals, and implement plans for achieving those goals.
Have a working knowledge of Microsoft Suite of Products, including Word, Excel, PowerPoint, Access, Outlook (email), and the Internet

Benefits

Ivyhill has a competitive benefits program which includes medical, dental and vision; Life and AD&D insurance; Short- and Long-Term Disability; supplemental Life insurance and a 401(k) Plan.

Apply

Apply at Ivyhill Technologies LLC

About the Company

Ivyhill Technologies

Enterprise information management and IT services

Ivyhill Technologies provides enterprise information management services to commercial businesses and government agencies (federal, state, and local). Its offerings include Information Management, Infrastructure Support, Application Development, Cybersecurity Services, and Human Resources Consulting, delivered with cost-effective solutions and quality staffing. The company works by partnering with customers to understand objectives and then delivering end-to-end services—from managing information and infrastructure to developing applications, securing systems, and supporting human resources needs. Ivyhill differentiates itself by combining broad service capabilities with a focus on cost efficiency and reliable staffing to both commercial and government clients in a dynamic business climate. Its goal is to help customers meet their objectives while exceeding expectations through dependable, aligned information management and technology services.

Company size: 11-50
Company stage: Not listed
Total funding: Not listed
Headquarters: College Park, MD
Founded: 2015

Recently Posted Jobs

Explore more opportunities at Ivyhill Technologies

See more jobs