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The primary purpose of the Referral Management Liaison is to serve our customers by addressing authorization / referral issues through fast and accurate problem identification, routing to the appropriate department or Vice President of Market Operations (VPMO) and Director of Market Operations (DMO) when applicable.
Positions in this function are responsible for first-level response and resolution of escalated issues with external and internal customers. Responsible for the overall delivery of benefits and services by providing support and guidance to existing and potential customers to ensure continued membership.
Serve as the liaison to a complex customer base to manage first level response and resolution of escalated issues with external and internal customers
Identifies and resolves operational problems using defined processes, expertise and judgment
Investigate claim and / or customer service issues as identified and communicate resolution to customers
Provide feedback to team members regarding improvement opportunities
Provides expertise and customer service support to members, customers, and/or providers
Primary functions are performed at a Military Treatment Facility (MTF), on a military installation.
The Referral Management Liaison (RML) serves as the Referral Liaison for all MTF referrals and authorizations / provider support, and Medical and Case Management (CM)
Works with the Lead RML and the VP / DMO to assist in building and maintaining relationships between the UnitedHealthcare Military & Veterans (UHC M&V) team, and MTF staff and leadership. Underlying all of these functions are two over-arching goals; optimize TRICARE beneficiary health and healthcare, and the utilization of MTFs
Maintain ongoing communications with the MTF Referral Management Center and MTF TRICARE Operations staff to resolve identified referral and authorization issues
Process STAT and Urgent referrals from the MTF, as well as assist in the processing of a minimum daily average of five routine referrals within the geo-pod with an expectation of processing additional referrals as capacity allows
Assist MTF staff with inquiries correspondence, claims issues and Urgent referrals
Correct misdirected referrals
Supports Medical Management team on improvement in Referral Processing, Utilization Management (UM), CM, and Integrated Behavioral Health (IBH) initiatives by identifying and tracking systemic issues and supporting implementation of resolution as needed
Collaborate with the MTF staff to identify and refer patients for potential CM, Disease Management (DM) or other services, in accordance with UHC M&V processes
Operate in compliance with UHC M&V policies, procedures and performance standards Maintain close communications with the Lead RML or VP/DMO
Actively participate in meetings with MTF staff pertaining to primary responsibilities Assist the VPMO / DMO in planning meetings with the MTF
Deliver or assist in presentations about TRICARE when Beneficiary Education Representatives (BER) and Beneficiary Enrollment Specialist (BES) are unavailable
Identify and report potential risk management and quality of care issues to the Lead RML, and/or the VPMO / DMO
Provide information to the MTF on the availability of local healthcare resources and programs as requested
Provide assistance to civilian providers with benefits, referrals, claims, Right of First Refusal (ROFR) process, Command Approvals, and eligibility in partnership with Provider Services or the Network Manager
Occasionally, may accompany Provider Relations personnel on provider visits, as requested, to educate them on referral process, claims, as requested by the MTF to maintain local provider relationships
RMLs assigned to support Parent MTFs or USCG Districts will have responsibility for multiple sites
Responsibilities will include acting on behalf of the Lead RML and VPMO/DMO as needed.
Perform other duties as assigned
Extensive work experience within own function
Work is frequently completed without established procedures
UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.
We are committed to introducing innovative approaches, products and services that can improve personal health and promote healthier populations in local communities. Our core capabilities... in clinical care resources, information and technology uniquely enable us to meet the evolving needs of a changing health care environment as millions more Americans enter a structured system of health benefits and we help build a stronger, higher quality health system that is sustainable for the long term.
We serve our clients and consumers through two distinct platforms:
?UnitedHealthcare, which provides health care coverage and benefits services.
?Optum, which provides information and technology-enabled health services.