Patient Service Rep/Medical Appointing

Aug 28 2018
TriWest Healthcare Alliance |Honolulu|Full Time
Category: Healthcare
Job Description


Job Summary


Directly interacts with a variety of customers daily. Processes healthcare authorizations approved by VA, places outbound calls and receives calls to schedule Veterans’ appointments. Ensures accurate data entry and completion of authorization data from referral/authorization forms, medical documentation, existing data contained in the TriWest medical management system and customer information. Contacts providers to obtain missing medical documentation to assure compliance with timelines. Provides back-up by phone to facilitate patient transfers as requested by VA. Works in a detailed, multi-tasked and fast-paced production environment.


Government Reporting






Education & Experience




o      High School diploma or G.E.D
o      At least one fullyear experience working in a call center and/or medical appointing in a medical office
o      Experience using Microsoft Office, the Internet and medical/health systems
o     Knowledge of medical terminology normally obtained through a medical certification OR work experience using and understanding ICD and CPT codes




o     More than two years experience working in a call center and/or medical appointing in a  medical office
 College coursework in  the healthcare or equivalent field


Key Responsibilities


Key Responsibilities


o      Researches and contacts the VA POC for essential missing information that cannot be located in the TriWest medical management system.
o      Schedules appointments for Veterans using the medical management appointing function for specialty care in the provider network in accordance with VA guidelines and TriWest desk procedures.
o      Manages multiple tasks lists in accordance with directed timelines.
o      Initiates automated or live outbound phone calls to Veterans and providers within timelines.
o      Contacts network providers to schedule, reschedule or cancel Veterans’ appointments.
o      Consistently displays professional and courteous service skills to internal and external customers.
o      Utilizes various software applications
o      Understands procedures and processes of the VA  program...
o      Responds to inquiries from Veterans and providers regarding specific aspects of the VA program. Information and assistance includes providing details about referrals, authorizations, and the location and use of network providers and when necessary redirect to the VA for further healthcare services.
o      Demonstrates proficiency with the medical management system for tracking and updating medical documentation from the network providers for every patient encounter.




o      Protects the privacy of health information of patients when using or disclosing Protected Health Information (PHI). PHI is any information about health status, or healthcare services that is linked to an individual.
o      Takes appropriate measures to comply with HIPAA regulations to protect privacy of beneficiaries' health information.
o      Tracks, receives, reviews medical information for completeness in accordance with VA and TriWest requirements.
o      Confirms medical documentation is received and complete to allow payment of a claim.
o      Documents every aspect of appointing, patient transfers, inquiries or complaints thoroughly in the medical management system.
o      Documents all communications involving Veteran and provider contacts.
o      Coordinates complete resolution of service issues by interfacing with the TriWest Complaints & Grievance Specialist and other departments .




o       Receives and reviews faxed documents to ensure appropriate entry into the medical management system.
o      Understands and utilizes the grievances and appeals process available to dissatisfied beneficiaries and providers.
o      Identifies potential discrepancies in the medical management system to assure quality program compliance.
o      Consistently meets department productivity and performance metrics.
o      Performs other duties as assigned.
o      Regular and reliable attendance is required.




Technical Skills


Proficient data entry skills; Ability to achieve a Meets Expectations rating or higher on monthly production bonus scorecard


Team-Building / Team Player


Influence the actions and opinions of others in a positive direction and build group commitment.


Problem Solving / Analysis


Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.


Organizational Skills


Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.


Multi-Tasking / Time Management


Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.


Information Management


Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.


Independent Thinking / Self-Initiative


Critical thinkers with ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources.


High Intensity Environment


Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.


Empathy / Customer Service


Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.


Coping / Flexibility


Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.


Computer Literacy


Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.


Communication / People Skills


Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate.


Commitment to Task


Ability to conform to established policies and procedures; exhibit high motivation.


Working Conditions


Working Conditions


o      Ability to cover any work shift  Monday - Friday and Sunday, with no travel
o      Ability to work overtime, if needed
o      Works within a standard office environment
o      Extensive computer work with prolonged sitting and wearing of headset
o      A VA-approved security clearance may be required