Clerk, Referrals

Job Title: Clerk, Referrals

Reports To: Supervisor, Medical Records and Referrals

Job Summary: Processes all standard referrals, internal/external Behavioral Health referrals, internal Registered Dietician referrals, and diagnostic orders requiring a prior authorization, provides loop closure for all ordered referrals to support PCMH model and gap closure efforts, offers clerical support to providers, support staff, outside specialist agencies, and insurance carriers, all while providing excellent customer service to all CCHCI patients.

Qualifications and Requirements:

The requirements listed below are representative of the knowledge, skill, and/or ability required. Job duties may be modified at any time based on business needs.

Essential Job Duties and Responsibilities:

Processing of Referrals and Diagnostics Requiring a Prior Authorization

• Processes standard referrals, internal behavioral health, internal registered dietician, and external behavioral health referrals according to policies and procedures.
• Processes diagnostics orders according to policies and procedures.
• Process high priority referrals and diagnostics within 24 hours.
• Verify patient benefits with their insurance carrier for coverage details.
• Review's referral paperwork to ensure that referrals are appropriate for the insurance carriers.
• Fax referral packet to include necessary clinical documents to specialist or diagnostic facility.
• If a prior authorization is required, acquire and document referral information from provider in the insurance portal for approval.
• Follows-up to ensure that all required documents have been received by insurance carrier for prior authorization approval for the referral to be processed.
• Communicates with provider and provider team when a prior authorization has been denied and a peer-to-peer is necessary.
• Facilitates patient and provider requests for all changes to existing referrals and diagnostics ordered.
• Documents in order management and telephone call templates within EHR for all ordered referrals and diagnostics.
• Maintain knowledge of CPT codes required for processing ordered referrals and diagnostics.
• Send completed referral and diagnostic orders via USPS mail and/or via Patient Portal to patients.

Loop Closure

• Obtains Referral notes from specialists as required.
• Obtains results for ordered Diagnostic referrals.
• Runs reports according to policies and procedures to follow up on open referrals and diagnostics until visit notes or result are received by specialist.
• Communicates with patients and CCHCI providers to facilitate cancellation of referrals and diagnostics no longer necessary.
• Coordinates with patients, specialists, and CCHCI care coordinators to address barriers for completing referrals and diagnostics.
• Facilitates face-to-face scheduling of patients with their assigned PCP to address concerns regarding the completion of or lack of compliance with ordered referrals and diagnostics.
• Electronically filing of received reports and specialist notes.
• Maintain access to various portals for obtaining electronic records.
• Send reminder letters to patients via USPS mail for incomplete referrals and diagnostics ordered.

Provides Excellent Customer Service

• Answers telephone calls.
• Responds to caller questions as able and/or transfers calls to appropriate party.
• Takes and documents messages as appropriate.
• Interacts with and assists patients and staff in a professional manner.

Additional Administrative Duties

• Review and process incoming faxes.
• Daily review patient portal messages regarding ordered referrals and diagnostics.
• Addresses incoming EHR tasks for all CCHCI clinic sites that pertain to referrals and diagnostics.
• Completes "order and processed" report to capture any referrals or diagnostics that were untasked by the ordering provider.
• Adheres to policies and procedures supporting HIPPA guidelines.

Required Minimum Qualifications - Education, Experience, Certificates & Licenses:

• High School Diploma or GED.

Preferred Qualifications- Education, Experience, Certificates & Licenses:

• Experience in medical records or referrals preferred.
• Knowledge of insurance carrier's practices associated with submitting prior authorizations and verifying benefits preferred.

Required Language Skills:

• Ability to comprehend and compose instructions, correspondence, and communications in English in both oral and written format.

Physical Requirements:

• Ability to occasionally exert enough force to move objects weighing up to 10 pounds.
• Ability to continuously remain in a stationary position.
• Ability to occasionally move about inside the workplace to access files, office machinery, etc.
• Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
• Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
• Ability to discern the nature of sounds at a normal spoken volume.

Other Required Knowledge, Skills, and Abilities:

• Ability to add, subtract, multiply and divide, using whole numbers, common fractions, and decimals.
• Ability to gather data in an organized fashion from varied sources.
• Ability to take direction and perform assignments accordingly.
• Knowledge of all aspects of insurance referral process.
• Computer literacy required.
• Understands covered services and contracted physicians enrolled with various insurance carriers.
• Ability to provide excellent customer service by mail, telephone, and in-person.

Work Environment & Conditions:

• Work environment is typical of an administrative office setting with no substantial exposure to adverse environmental conditions.