Outpatient Referral & Authorization Representative - Full Time

Position Title: Outpatient Referrals & Authorizations Rep      Position Code:         RpOPRAuth-XXXX

Department: Outpatient Scheduling Center                             Safety Sensitive:    Yes            

Reports to: Outpatient Scheduling Manager                            Exempt Status:       No

Position Purpose:

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country.

This position is responsible for financially clearing all outpatient referrals as ordered by the referring

provider. Financial clearing includes but not limited to, processing referral within provider EMR, verifying

insurance eligibility and benefits, contacting patients to discuss coverage, obtaining authorization when

necessary, maintains statistical information regarding payers, communicating with providers and staff of

denials, and documenting and scanning all communication into referral and EMR.

Provides guidance as needed to the department and provider office representatives when required.  Establish

and maintain inter-departmental communication within the hospital and work closely with the Medical Office.

Coordinators in the respect of issues that arise effecting orders. Other duties as assigned.

Key Responsibilities [List of material responsibilities and essentials duties which must be completed in achieving the objectives of the position]

Outpatient Referrals and Authorizations Rep:

Consistently demonstrates a willingness to assist co-workers in a courteous manner to support department efficiency.

Develops and maintains good human relations skills by practicing AIDET, KRMC’s values, and behavioral standards with employees, patients, medical staff, and visitors in accordance with performance of duties.

Maintains positive attitude and functions as a team player.

Protects patient information and hospital financial reimbursement by inputting authorization information.

Verifies the insurance and ensures that all notification/authorizations are completed in a timely manner as well as ensuring patient services are a covered benefit.

Inputs notes pertinent to financial information to assist billing department in payment of the claim.

Contacts responsible party of outpatient referral by telephone to advise of insurance coverage rate when insurance does not cover 100%; professionally advises responsible party of payment requirements and follows hospital policy in establishing payment arrangements or advises other referral sources. Contact is made before referral is sent to referring provider/department.

Meets productivity standards for working incoming referrals to schedule financially cleared outpatient visits in a timely manner.  

Referrals should be processed within three (3) business days.  Authorization should be initiated within three (3) business days.

Maintains statistical information regarding payers and communicates info routinely to Outpatient Scheduling Center Supervisor/Manager.

Assists with education to Outpatient Scheduling Reps.

Completes all assigned duties, and other duties as assigned, accurately and in a time

Lead Outpatient Referrals and Authorizations Representative:

In addition to above key responsibilities of an Outpatient Referrals and Authorizations Representative, a Lead Outpatient Referrals and Authorizations Representative:

Provides day to day leadership and supervision of Referrals and Authorization team members, trains, and orients new hire reps. and works with Supervisors to provide continuous training of existing staff.

Performs QA audits, works account checks, and responds to account denials.

In the absence of the supervisor the Lead Outpatient Referrals and Authorizations Representative assists with the staff to ensure appropriate coverage.

Participates in the interviews for hiring new staff within the unit, as well as provides feedback to the supervisors for performance evaluations.

Identifies, supports, and manages process improvement initiatives for the team.

Collaborates with management to assist in the day-to-day operations of the team

Qualifications [Statements regarding minimum educational and experience qualifications, required proficiencies with specialized knowledge, computer proficiencies, military service, required certifications, etc.]

Education: High school graduate/GED or 2-5 years healthcare experience in lieu of education requirement.

Experience: Six months or more of progressive work experience.

Skills:

Ability to communicate effectively with others.

Manage multiple priorities and tasks.

Maintain attention to detail.

Knowledge of and ability to use computer hardware and software applications.

Preferences [Preferred attributes for the position which are not absolutely required in the minimum qualifications (i.e., multi-lingual, master’s degree)]

Experience:  One-year hospital outpatient referrals and/or insurance verification experience preferred.

Skills:  Knowledge of medical terminology, coding rules and guidelines preferred.

Special Position Requirements [Optional section: any travel, security, risk, hazard, or related special conditions which apply to the position]

Bloodborne disease exposure category II:  Expected duties have possible, but not routine, potential for exposure to blood, body fluids or tissues.

Other potential hazard(s):  Possible exposure to chemical substances and to hostile individuals.

Work Requirements [Optional section: work requirements for physical or other important issues which relate to the job]

Employee must be capable of consistently reaching and/or working above and below shoulder level; sitting at computer terminal 90% of time per day; walking or on feet 10% of time per day with frequent bending, squatting, kneeling, standing; communicating using telephone.

ACKNOWLEDGEMENT:

This job description applies to all KHI facilities and is representative of the essential job duties this position will perform. Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Date Staff Position Description Created / Revised: 10/30/2018; 8/06/2021; 8/5/2024; 1/30/2026; 6/1/2026