AltaMed Health Services Specialist, Referral I in Commerce, California

AltaMed Health Services

We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, veteran status, or any other basis protected by applicable federal, state or local law.

Job ID 2016-3971

Location US - CA - Commerce


This position is responsible for processing referral requests from various sources to ensure compliance with federal, state, or Health Plan specific turnaround time requirements. The referral specialist is accountable for facilitating timely authorizations and notifications as well as other referral management functions.


  1. Manages the authorization process and other issues in a courteous and professional manner.

  2. Collaborates with Customer Service Representatives via the CSR module to ensure referrals are processed for patient and/or provider referral inquiries

  3. Input data into the Medical Management system to ensure timeliness of referral processing.

  4. Verifies member benefits and eligibility upon receipt of the treatment authorization request.

  5. Performs trouble-shooting when problems situations arise

  6. Makes recommendations regarding changes, improvements or enhancements to appropriate staff.

  7. Ensure timely provider and member oral and written notification of referral decisions.

  8. Coordinates with referral nurse and/or Medical Director for timely referral processing

  9. Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making

  10. Facilitates LOA processing by sending request to Provider Contracting for non-contracted providers or facilities, when applicable

  11. Facilitates LOA processing with the Health Plan for non-contracted facilities

  12. Perform additional duties as assigned.

Measurements of Success:


  1. Meet the established performance & productivity targets. Measurement: department's Performance Metrics.

  2. Effective time management demonstrated by meeting the established turn-around times and all regulatory and health plan requirements. Measurements: 100% of audits completed and documents submitted within the required time line. No more than three CAPS per health plan per audit.

  3. Managing multiple priorities, demonstrated by ease and productivity to transition between multiple tasks. Measurement: Department Performance Measure.

  4. Team player, achieved through assisting co-workers with their workload as asked by the Lead or others and completed cross-training, and serve in roles not their own during the year Meet Productivity Targets, as managed and communicated through the Productivity Report

  5. Highly effective communication with members, external constituents, and internal stakeholders.


  1. All items listed under "Meets Expectations," and:

  2. Problem solving skills demonstrated by identification, recommendation, and implementation of tactics to improve productivity and team work.

  3. Taking initiation.

  4. Leading by example. This is measured by AIDET Validation and input from the clinics and other customers obtained as a part of the annual Performance Review.


  1. High school diploma required. Medical Assistant Certificate or Medical Billing Certificate preferred.

  2. Workable knowledge of Medi-Cal, CMS, Federal and state regulatory requirements applicable to the position, as well as CPT and other pertinent medical coding.

  3. Minimum one year of experience working in a medical billing environment (IPA or HMO preferred), with pre-authorizations and reimbursement regulations pertaining to Medi-Cal, CCS and other government programs required.

  4. Bilingual English/Spanish preferred.