Referral Management (Non-Nurse) Reviewer

Referral Management ReviewerZimmerman Associates, Inc. (ZAI) is seeking to hire multiple Referral Management (Non-Nurse) Reviewers to support our contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Region's premier authority for appointment coordination and referral management services for beneficiaries within the Defense Health Network.Pay Rate: $23.56 per hour plus $4.93 Health & Wellness FringeRole and Responsibilities:Referral Management (Non-Nurse) Reviewers will facilitate centralized product line and specialty referrals for Active-Duty Service Members and TRICARE Prime beneficiaries enrolled at Military Treatment Facilities (MTFs) within the National Capital Region.This is an onsite opportunityQualifications / Skills / Experience:Minimum of an Associate's degreeAt least 2 years of experience in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance ReferralU.S. Citizenship required, with the ability to obtain a Public Trust ClearanceKnowledge of medical care criteria such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs), or other evidence-based Military Health System (MHS) guidelinesFamiliarity with medical terminology and ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, and release of medical information protocolsExcellent communication and interpersonal skillsStrong customer service orientationUnderstanding of Access to Care Standards within the Direct Care SystemAttention to detail, including correct use of deferral codesStrong organizational skills with ability to prioritize tasks and manage time effectivelyProficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Access, Outlook) and internet navigationEssential Tasks:Review and process referrals for administrative and clinical completeness and appropriateness, completing disposition within 24 hours of referral dateCollaborate with appointing centers, case managers, product line nurses, providers, clinics, managed care contractors, and other healthcare team members to ensure appropriate use of Direct Care and civilian network resourcesEnsure patients are scheduled with the right provider, at the right time and placeReview compliance with Specialty Referral Guidelines (SRGs) per IRMAC protocolsComplete and return Clear Legible Reports (CLR) to ordering civilian providers within required Return of Favorable Response (ROFR) timelinesManage telephone, written, and electronic communications regarding specialty appointments and referralsMonitor and process referral management worklists (e.g., Genesis Work Lists) to ensure timely consult processingCommunicate referral status to patients, including benefit counseling and advocacy resources as neededReschedule or redirect patients within 3 days when referrals are disapproved or invalid, advising on other care options and Line-of-Duty issuesReceive and enter ROFR referrals in MHS-GENESIS from Military Contractor Support Centers (MCSC) portals for assigned specialties/product lines, adhering to all timelines and business rulesVerify patient eligibility and update demographics in MHS-GENESISDocument patient interactions, especially when appointments are refused, and coordinate with Beneficiary Counselor and Assistance Coordinator as appropriateCoordinate with product line nurses and clinics for special accommodationsInterface with MCSC and multidisciplinary teams to ensure referral appropriatenessSubmit referrals to non-network providers for TRICARE Service Center medical necessity reviewsMonitor referral management voicemail and return patient calls within established guidelinesProvide External Provider Referral Online (EPRO) information as requestedClose unused referrals following DHA IPM and NCR Medical Directorate policies, notifying ordering providers accordinglyOrient and train new IRMAC staff on referral processes and timelinesPerform other duties as assignedZimmerman Associates, Inc.

is an equal opportunity employer. We comply with Federal and State Equal Opportunity laws and consider qualified applicants without regard to race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, veteran status, or any other protected status.