Reports To: Manager, Care OperationsRole OverviewAs our Care Coordinator specializing in Prior Authorizations & Referrals, you will manage back-office responsibilities including referral management, prior authorizations, specialty pharmacy & infusions, and medical records to help deliver and implement clinical strategies and support member care coordination in collaboration with a multidisciplinary clinical team. You will use a high level of attention to detail, organization, and communication skills to obtain, manage, and follow up on member referrals and prior authorizations to ensure key care plan goals are met.What You'll Do: Key ResponsibilitiesCollaborate with a multidisciplinary team of care providers (including NPs, RDs, Behavioral Health Providers) to provide a whole-person approach to member care.Coordinate, track, and communicate patient referrals, prior authorizations, and medical records to promote team awareness and patient safety.Provide complete and accurate registration of referrals and authorizations, including patient demographics, insurance information, and clinical documentation to external providers and specialty pharmacies.Offer proficient knowledge of referrals, insurance requirements, and the prior authorization process to internal and external resources, eliminating barriers to care and following up on progress toward key goals.Apply knowledge of CPT and ICD-10 codes to obtain authorizations in a timely manner while demonstrating understanding of payer medical policy guidelines.Initiate appeals for denied authorizations and maintain close follow-up to ensure positive member outcomes.Engage in external coordination of pharmacy support services to ensure members receive all necessary support throughout the prior authorization process.Assist members in accessing services, providing personalized customer service while maintaining close communication with the care coordination team.Manage key reports and track relevant data to identify successes and drive refinements in operational processes.What We're Looking For: Qualifications & RequirementsRequiredBachelor's Degree in Healthcare administration or equivalent course workMinimum of 2-3 years experience in healthcare coordination, care, or case management within a remote digital healthcare spaceCompleted degree in a health and science related field (biology, psychology, health science, nutrition, nursing, etc.).Fluent in healthcare terminology with a working understanding of clinical concepts.Background knowledge navigating health insurance plans and coverage, with ability to provide benefits breakdown analysis to consumers.Comfortable and competent with common administrative technologies (Zoom, Slack, Office or equivalent), charting electronically in EMR/EHR systemsPreferredExperience working in telehealth or a digital health environment.Strong critical thinking skills with ability to triage accurately and escalate appropriately.Experience in a high-growth startup or mission-driven healthcare organization.Compensation & BenefitsSalary Range: $47,000 – $52,000 (commensurate with experience)Health Benefits: Employer-sponsored medical, dental, and vision coverageTime Off: Unlimited PTO + 11 paid company holidaysRetirement: Eligibility to contribute to 401(k)Work Style: Remote-first — work from home anywhere within our approved statesGrowth: Tailored professional development opportunities as we scaleLife Concierge: Access to Overalls, because we know life happensAbout Oshi HealthOshi Health is a virtual digestive health practice on a mission to transform GI care. We combine compassionate, multidisciplinary care with innovative technology to help people with chronic digestive conditions get the answers and relief they deserve. When you join Oshi, you're joining a team and a mission that's changing what great healthcare looks like. Oshi Health is revolutionizing GI care with a digital clinic model that provides easy, convenient access to an integrated and multidisciplinary care team that takes a whole-person approach to diagnosing, managing, and treating digestive health conditions. We take time to get to know each patient, develop a personalized, whole-person care plan that includes identification of symptom triggers and prescription of evidence-based interventions, including medications, dietary changes, and mental health support.For Every Oshi Team Member We Want:Genuine passion for improving patient lives and transforming GI careStrong communication skills and emotional intelligenceComfort in a fast-paced, remote-first, mission-driven environment
3 months ago