Job Description

Position Title: Outpatient Referrals & Authorizations Rep

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

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

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

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

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

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