Specialty Navigator II, Gastroenterology Procedure, Remote, Massachusetts Only, Fulltime

Atrius Health, an innovative healthcare leader, delivers an effective system of connected care for more than 690,000 adult and pediatric patients at 30 medical practice locations in eastern Massachusetts. Atrius Health’s 645 physicians and primary care providers, along with 420 additional clinicians, work in close collaboration with hospital partners, community specialists and skilled nursing facilities. Our vision is to transform care to improve lives. Atrius Health provides high-quality, patient-centered, coordinated, cost effective care to every patient we serve. By establishing a solid foundation of shared decision making, understanding and trust with each of its patients, Atrius Health enhances their health and enriches their lives. Atrius Health is part of Optum, a health services company focused on building the leading value-based care system in the country.

SUMMARY

Reporting to and working under the general direction of the Supervisor(s) and Manager of the department, reviews complex referral requests and evaluates and assigns appropriate specialist for the patient. Works with patients and providers to understand services being requested. Interviews patients as needed to obtain full understanding of what information is being requested. Works closely with Specialty Nurses to ensure clinical handoffs are safe and appropriate. Coordinates care both within Atrius Health and with external partners.

GENERAL DUTIES AND RESPONSIBILITIES

• Reviews referral information from clinicians for pertinent information regarding tests, consultations and procedures. Verifies demographics and insurance information. Work is highly complex and detail oriented, involving frequent contact with a range of internal and external contacts as well as the need to understand terms and processes of multiple payers
• Reviews referral information from work queue for pertinent information regarding referral requests
• Reviews each external referral for opportunity to convert to internal referral and reviews options with patients. Redirects patients with managed care products appropriately ensuring clinical handoff is safe using expertise of specialty nurses. Ensures adequate information is obtained and relayed when care is moved.
• Explains insurance benefits and options to patients. Explains denials to patients. Keeps patient informed of status of all referrals (approved and denied). Notifies patients of scheduled appointments and confirms appointment by mail including confirmed location and map of destination. Informs patient of any preparation that must be completed prior to the appointment. Contacts patient if insurance coverage issues arise during the referral process so that patient can work directly with the insurance company
• Promotes the Atrius Health System of Care by highlighting internal providers and their expertise
• As needed, places orders to start the referral process for the PCP on behalf of patients who have booked appointments and call for the referral. Researches the visit notes to determine if a referral was intended as well as processing referrals for follow-up or annual visits that require a referral
• Schedules patients for tests, consultations, services and procedures with other departments, local private offices, and/or outside vendors/providers.
• Answers phone calls, faxed requests and other inquires relating to referrals and communicates with the physicians and clinicians to acquire authorization or to inform them of patient issues or clinical paperwork needed
• Researches questions/concerns from patients regarding bills and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process. Refers patients to appropriate staff (e.g., patient account representatives) for billing issues related to insurance benefits and services covered under the benefits plan
• Works in collaboration with the person designated as the Practice’s Benefits Coordinator to maintain cost control, ensure that services provided are within benefit plan guidelines, and that necessary policies and procedures are followed when dealing with non-preferred providers/vendors. May coordinate second opinion requests
• Works with supervisors to ensure patients are receiving timely responses and detailed answers to their complex questions.
• Researches questions/concerns from patients regarding billing and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process
• Receives escalated issues and stat same day calls; determine appropriate action and/or works with clinical team for decision
• Effectively deescalates issues with upset patients and practices. Uses advanced listening techniques to understand the issue and give patients options as they are available. Escalates to supervisors only as needed
• Supports roles within the Navigator. Trains and teaches as needed
• Participates in problem solving activities, focusing on productivity and quality. Works with supervisors to ensure continuous improvement of the department.
• If needed, contacts appropriate parties to obtain referral authorizations and verify coverage (e.g., the Authorization Services Unit (ASU), National Imaging Associates (NIA) or individual insurance companies). Certain departments may also need to contact additional outside agencies for approval (e.g., American Imaging Management or Med Solutions)
• Performs other duties as assigned

SUPERVISORY RESPONSIBILITIES

• None

EDUCATION/LICENSES/CERTIFICATIONS

A minimum of a High school diploma (or equivalent education, experience or training) is required

EXPERIENCE

A minimum of three years in a clinical or customer service setting preferred. Must be able to respond knowledgeably to a wide range of patient issues for every contracted and non-contracted payers, including government and non-government payers. Strong technical proficiency in Microsoft, scheduling software and electronic medical records systems (Epic or equivalent). Strong problem solving and complex patient management skills preferred. Relevant experience in the managed care environment preferred. High level of understanding of health insurance products and limitations in order to match patient to available providers.

SKILLS

• Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations
• Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance
• Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents
• Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager
• Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers
• Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customer
• Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations
• Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members

Atrius Health is committed to a policy of non-discrimination and equal employment opportunity. All patients, employees, applicants, and other constituents of Atrius Health will be treated with respect and dignity regardless of race, national origin, gender, age, religion, disability, veteran status, marital/domestic partner status, parental status, sexual orientation and gender identity and/or expression, or other dimensions of diversity.

BENEFITS INCLUDE:

• Up to 8% company retirement contribution
• Generous Paid Time Off
• 10 paid holidays
• Paid professional development
• Generous health and welfare benefit package