| Job Category : | Management |
| Company Name: | iCallidus |
| Position Name: | Referral Management Coordinator |
| Location : | Bethesda, MD 20816 |
| Job Description : | Overview: iCallidus is seeking a Referral Management Coordinator to join our team! The Referral Management Coordinator will provide care coordination and referral management activities in the Integrated Referral Management and Appointing Center (IRMAC).At iCallidus, you will be invited to participate in learning opportunities to grow your career, encouraged to foster a work-life balance and rewarded for your meaningful contributions. We serve as a key partner to government agencies using leading –edge technologies and strategies to re-invent the way things get done. Our culture is built on inclusion, collaboration, high-performance and opportunity. We have an exciting opportunity for you to join our diverse group of innovators.Responsibilities: Performs referral review duties under the direction/guidance of the product line nurse(s), IRMAC Referral Management Leadership. Reviews all referrals for administrative, clinicalcompleteness and appropriateness. 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, ensure that patients are booked at the right time, with the right provider, at the right place of care. * Under the direction and guidance of product line nurse identifies required tests, labs, radiology studies and other pre-requisites specific to each assigned specialty/product line prior to dispositioning using CHCS, AHLTA, HAIMS, Essentris, Humana Government portal, and other electronic health records or databases. Consult and collaborate with assigned product line nurse for clinical guidance as needed or instructed.Coordinates and facilitates process for research and communicate with requesting providers, product line nurses, manage care support contractor, and others to ensure complete medical information is available in order to make informed decisions about a referral matter.Send communication to ordering providers when directed by Referral Management team lead or product line nurse. This includes but is not limited to communication regarding requests for additional medical/clinical information, consult closures, clarification of care requestedDemonstrates proficiency in utilizing Composite Health Care System (CHCS), Armed Forces Health Longitudinal Technology (AHLTA), ESSENTRIS, CCS/CareRadius (RMS), Managed Care Support Contractor’s portal, MHS GENESIS, and AVAYA systems.Accurately processes referrals per the guidelines established from the order date or date consult was directed to queues managed by IRMAC.Accurately enters/processes/tracks/closes the Right of First Refusal (ROFR) referrals per the guidelines established.Receives and enters ROFR referrals in CHCS from the Managed Care Support Contractor’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. Process all ROFR cases in the interest of optimizing care in the MTFs. Reports concerns related to the ROFR referral process to team lead as needed.Completes and returns all Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.Document and update all ROFR cases in the Integrated Referral Management and Appointing Center (IRMAC) database. Prepare, review, consolidate, and report data to demonstrate understanding of the ROFR Process. Accurate data entry and attention to detail. Review monthly reports on ROFR data with data analysts, leadership, and team lead.Educate NCR providers, staff, patients on the ROFR process as needed.Maintains the MTFs Specialty Capability Table and Coarse of Action (COA) status for assigned specialty clinics.Provides recommendations and/or assistance to staff, patients, and other members of the healthcare team when providing guidance regarding access to care options as related to patient eligibility and beneficiary status.Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits.Coordinates with specialty referral clinics (internal or external) to obtain special patient instructions and/or tests required prior to appointment. Provides pre-appointment instructions to patients as well as the details regarding their appointment (i.e., date/time, provider, and location). Ensures patients receive necessary documentation appropriate for the referred medical care visit.Verifies patients’ eligibility and that they are registered in CHCS. Ensure Defense Enrollment Eligibility Reporting System (DEERS) information is up to date. Update demographic information when needed. When working with ROFR referrals, if patient is not registered, will register patient in CHCS based on DEERS information.Manages and utilizes multiple complex computer systems for appointment scheduling. Schedules referral appointments in accordance with booking protocols and required Access to Care Standards within the direct care system or outside the MTF with network/non-network providers. Ensures appointing is done within the established guidelines of all referrals.Documents in CHCS, explains 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 high valuable cases.Interfaces with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as need to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center (TSC) for medical necessity/appropriateness review.Performs data collection and review to identify areas requiring intensive management. Refers to case management officials if needed.Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management voicemail to ensure patient calls are returned within the guidelines established.Receives and appropriately forwards clinical concerns from patients to product line nurse or IRMAC Referral Management Leadership.Advises patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy. Advises of Line-of-Duty issues as it relates to referral management.Obtains pertinent information from patients/callers, referrals, physician or other officials. Enters data in CHCS, AHLTA, MHS GENESIS, Referral database, and other office automation software programs as appropriate.Assist with other duties within the Referral Management Office related to the processing referrals to Direct Care MTFs and Civilian Care per IRMAC responsibilities.Provides information about External Program Resource Office (EPRO) to requestors outside the National Capital Region (NCR) requesting care within the NCRAssists Medicare beneficiaries in coordinating their medical care within the Direct Care System. This includes scheduling appointments, ensuring pre-requisites are completed prior to specialty care appointments. If civilian care is warranted, navigator will provide notification/communication to Medicare eligible beneficiaries via Medicare packages or other method(s) as directed by IRMAC.Assists Medicare beneficiaries when civilian care is warranted by providing resources to patients to facilitate this process.Closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly.Understands, and acts as subject matter expert of the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care). Utilizes deferral codes appropriately. Understands access to care standards within the direct care system. Collaborates with manage care support contractor staff when civilian care is warranted.Travels within the National Capital Region to attend meetings/conferences/briefs as requested.Performs administrative duties that support the referral management process under the direction/guidance of the product line nurse(s), team lead, and/or IRMAC Referral Management Leadership. Assist with other duties not specified but within scope of and related to Referral Management/ROFR/Healthcare navigation.Orients and trains new IRMAC staff about the referral processes and timeliness.Assists with other duties not specified but within the scope of and related to referral management process.On occasion, is able to take on Team Lead responsibilities as requested by the Referral Management Team Lead.Benefits: Medical, Dental, Vision, 401(K), Fringe Benefits, Basic Life InsuranceVacation, PTO, Sick Leave applicable after the 90 Day Introductory Period.Qualifications: Education: Proof of License Practical Nurse Certification/Licensure from an approved National League of Nursing program. For non-licensed staff must have a bachelor’s degree or a minimum of 6 years experience, which demonstrates the ability to perform the duties of the position working in a Military Health System (MHS) referral management center or clinic.License/certification: Current, active, full, and unrestricted License to practice nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Practical Nurse. If non-licensed must meet experience qualifications.Experience: 6 years of clinical nursing experience is required within the last 48 months in a Military Health System (MHS) clinic and/or referral management center. If non-licensed must have a minimum of 6 years experience within the last 48 months, which demonstrates the ability to perform the duties of the position working in a MHS referral management center or clinic.License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.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-base guidelines identified by the Military Health System (MHS).The Contractor must have a working knowledge of medical terminology, Military Health System (MHS), VA-DOD Sharing Program, TRICARE, Health Insurance Portability and Accountability Act (HIPAA), release of medical information.Possess excellent oral and written communication skills, interpersonal skills, superior customer service and organizational skills. Have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.Work Environment/Physical Requirements. The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout the workplace and other military facilities.Initially, this is a remote position. Must be able to work on-site in Bethesda, MD on a permanent basis upon immediate notification.Monday through Friday, 7:30 to 4 pm*EEO Statement*iCallidus is an Equal Opportunity/Affirmative Action Employer. We do not unlawfully discriminate on the basis of race, color, religion, age, sex, creed, national origin, ancestry, citizenship status, marital or domestic or civil union status, familial status, affectional or sexual orientation, gender identity or expression, genetics, disability, military eligibility or veteran status, or any other protected status.Job Type: Full-timePay: $28.00 – $30.00 per hourBenefits:401(k)401(k) matchingDental insuranceFlexible spending accountHealth insuranceHealth savings accountLife insurancePaid time offVision insuranceSchedule:8 hour shiftDay shiftMonday to FridayNo weekendsCOVID-19 considerations:All employees are required to be fully vaccinated against the COVID-19 virus.Application Question(s):Do you hold an active Security Clearance?Do you have experience with the following Military Health System (MHS) such as Interqual, AHLTA, CHCS, DEERS?Do you have experience with referral management?Have you worked in a military setting and understand military terminology?Education:Bachelor’s (Required)Experience:clinical: 6 years (Required)License/Certification:LPN (Preferred)Work Location: One location |