SUMMARY

Provide consultation and administrative support for TRICARE beneficiaries. Ensure patient flow is optimized by assisting patients (CMHS Referral Management Team including the Central Referral Center- CRC and MTF Referral Management Centers) in processing referrals to specialty care.

 

ESSENTIAL DUTIES & RESPONSIBILITIES

Perform data collection and review to identify areas requiring intensive management. Coordinate specialty care referrals. Review specialty care referrals for appropriateness and completeness and route the referral to the appropriate place of care. Analyze data collected and prepare reports describing resource utilization patterns. Disseminate information to government members of collaborative teams and multidisciplinary hospital committees. Serve as functional expert in the area of health benefits and provide health benefits advice to patients. Maintain and track referral records. Participate with referral centers in providing, assessing, and improving a wide variety of customer services and relations. Assist in the management of all forms of communication between beneficiaries, referral centers, internal staff and providers, network/outside providers and ancillary healthcare workers. Plan and perform specialty referral reviews IAW established guidelines to provide quality cost-effective care. Conduct first level reviews for all referrals to specialty care. Act as a facilitator of professional and patient care activities. Interface with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as needed to ensure appropriateness of referrals. Identify cases that may benefit from alternative levels of care and involve the case manager as needed to provide direction in care management. Plan and prioritize utilization review  (UR)  activities to ensure identified patient needs are addressed promptly. Effectively utilize information systems to develop, design, analyze, update and record data. Facilitate the development and integration of utilization management (UM) review policies and procedures into operations. Perform Right of First Refusal (ROFR) coordination of specialty care referrals. Maintain regular and punctual attendance. Perform other duties as assigned.

 

SUPERVISORY RESPONSIBILITIES

None.