Referral Specialist III/Patient Access (Pre & Prior Authorizations, Appeals, Insurance) - Paragon Infusion

Anticipated End Date:

2025-05-23

Position Title:

Referral Specialist III/Patient Access (Pre & Prior Authorizations, Appeals, Insurance) - Paragon Infusion

Job Description:

Be Part of an Extraordinary Team  

A proud member of the Elevance Health family of companies, Paragon Healthcare brings over 20 years in providing life-saving and life-giving infusible and injectable drug therapies through our specialty pharmacies, our infusion centers, and the home setting.

Referral Specialist III/Patient Access (Pre & Prior Authorizations, Appeals, Insurance) - Paragon Infusion

Location: 3033 W President George Bush Hwy., STE 100, Plano, TX 75075

Shift: Business hours are 7 AM - 7 PM CST, specific shifts within business hours will be discussed during the hiring process.

Onsite Requirement: Tuesday, Wednesday, and Thursday are physically in the Plano, TX office. Virtual work is allowed on Mondays and Fridays after the training and acclimation period.

Onsite Training: Training will be in-person, full-time (Monday - Friday), 8 AM - 5 PM or 8:30 AM - 5:30 PM, for roughly the first five (5) weeks/30 days at the Plano, TX office.

The Referral Specialist III is responsible for providing support to a clinical team in order to facilitate the administrative components of clinical referrals.

How You Will Make an Impact

Primary duties may include, but are not limited to:

• Providing technical guidance to Referral Specialists assist callers with issues concerning contract and benefit eligibility for requested continuing pre-certification and prior authorization of inpatient and outpatient services outside of initial authorized set.

• Handling escalated and unresolved calls from less experienced team members.

• Training and/or Precepting Associates to deliver and enhance the ability to serve callers.

• Auditing the performance of Referral Specialists, assisting in the review of audit appeals and documenting audit statistics.

• Acts as a SME, ability beyond intake calls that include verifying eligibility and benefits for medical and pharmacy payers through multiple methods for specialty chronic and acute therapy services.

• Acts as liaison between patients, healthcare providers, infusion centers, pharmacy, and billing department to address issues.

• Ability to review and interpret clinical records to ensure patient meets medical policy guidelines for coverage, for completeness, and performs follow-up for additional information if necessary.

• Ability to initiate pre-determination, prior authorizations, and appeals for denials based on payer policy.

• Ability to read and interpret payer contracts, and payer policies to effectively manage referrals and mitigate risk of accounts receivable.

• Maintain knowledge of therapies serviced by Paragon, at minimum, therapy and diagnosis correlation and patient information required.

• Contacts physician offices as needed to obtain demographic information or related data.

• Manage referrals, documents communications, actions, and other data in the system.

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 3 years of experience in customer service experience in healthcare related setting; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, & Experiences:

• 4 years of experience in healthcare reimbursement, billing, or patient access, with specific experience in infusion therapy strongly preferred.

• Advanced knowledge of HCPCS, NDC, CPT, and ICD-10 coding for referral management is strongly preferred.

• Advanced knowledge of Medicare Local Coverage Determination is strongly preferred.

• Knowledge of insurance verification, pre-authorization, and claims submission process is strongly preferred.

• Strong mathematical, analytical, and problem-solving skills.

• Proficiency in computer skills, including electronic health record systems and Microsoft Office suite.

• An associate or bachelor’s degree is preferred, but not required.

• Ability to work independently and collaboratively.

• Ability to maintain professionalism and confidentiality.

Job Level:

Non-Management Non-Exempt

Workshift:

1st Shift (United States of America)

Job Family:

CUS > Care Support

Please be advised that Elevance Health only accepts resumes for compensation from agenci