Referral Management (Non-Nurse) Reviewer

Referral Management Reviewer Zimmerman 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.

At 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 Clearance Knowledge of medical care criteria such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs), or other evidence-based Military Health System (MHS) guidelines Familiarity with medical terminology and ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, and release of medical information protocols Excellent communication and interpersonal skills Strong customer service orientation Understanding of Access to Care Standards within the Direct Care System Attention to detail, including correct use of deferral codes Strong organizational skills with ability to prioritize tasks and manage time effectively Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Access, Outlook) and internet navigation Essential Tasks: Review and process referrals for administrative and clinical completeness and appropriateness, completing disposition within 24 hours of referral date Collaborate 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 resources Ensure patients are scheduled with the right provider, at the right time and place Review compliance with Specialty Referral Guidelines (SRGs) per IRMAC protocols Complete and return Clear Legible Reports (CLR) to ordering civilian providers within required Return of Favorable Response (ROFR) timelines Manage telephone, written, and electronic communications regarding specialty appointments and referrals Monitor and process referral management worklists (e.g., Genesis Work Lists) to ensure timely consult processing Communicate referral status to patients, including benefit counseling and advocacy resources as needed Reschedule or redirect patients within 3 days when referrals are disapproved or invalid, advising on other care options and Line-of-Duty issues Receive 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 rules Verify patient eligibility and update demographics in MHS-GENESISDocument patient interactions, especially when appointments are refused, and coordinate with Beneficiary Counselor and Assistance Coordinator as appropriate Coordinate with product line nurses and clinics for special accommodations Interface with MCSC and multidisciplinary teams to ensure referral appropriateness Submit referrals to non-network providers for TRICARE Service Center medical necessity reviews Monitor referral management voicemail and return patient calls within established guidelines Provide External Provider Referral Online (EPRO) information as requested Close unused referrals following DHA IPM and NCR Medical Directorate policies, notifying ordering providers accordingly Orient and train new IRMAC staff on referral processes and timelines Perform other duties as assigned Zimmerman 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.