Sr Referral Specialist

Summary:

The Sr. Referral Specialist reports to a Patient Access Manager. Under the general supervision of the Supervisor(s) of Patient Access ensures the quality of the referral process is upheld to departmental scheduling standards and is responsible for the integrity of the prior authorization processes for episode based medication referrals. Coordinates and ensures patients have received financial clearance from insurance companies and troubleshoot as needed.

Evaluates the incoming referral for information that is accurate and appropriately reflects the patient symptom to the requested treatment. Ensures quality control of the referral process is upheld by reviewing the accuracy and timeliness of referrals through monthly standard reports. Coordinates the effective and efficient processing and scheduling of all incoming referrals adhering to established timelines and departmental procedures

Responsibilities:

Receives and reviews all incoming referrals ensuring completeness and accuracy. Ensures all information is received including patient demographics insurance eligibility and authorizations. Communicates promptly with referring provider and/or patient regarding insurance coverage issues (e.g. non-participation status) so the patient may seek timely resolutions.

Confirms patient eligibility with insurance carriers/third party payors and obtains pre-authorization requirements in accordance with established medical policies.

Coordinates and ensures appropriate insurance authorizations are obtained and/or received in a timely manner. Coordinates and ensures appropriate insurance authorizations are obtained and/or received in a timely manner.

Collaborates with various Brown University Health personnel to resolve billing issues authorization denials and insurance denials/write-offs.

Evaluates and determines triage when reviewing the referral by following established clinic referral guidelines for complete/compliant information.

Determines if referral is in need of additional clarification evaluates the content matter to services requested and determines if the referral needs to be escalated to management for assistance or resolution.

Returns incomplete/non-compliant referrals based on triage guidelines to referring physician office indicating the reason for return.

Ensures quality control of the referral process is upheld by reviewing the accuracy and timeliness of referrals through Monthly standard reports.

Provides accurate and timely communication with patients referring providers and other staff.

Performs at benchmarked levels related to accuracy productivity quality and customer service as defined by industry standards and internal quality management.

Coordinates and provides guidance to other staff to ensure proper documentation is made in referral record. Assists and provides support to staff when entering all referral information into the electronic health record (EHR) for any external referrals received including demographics reason for referral and insurance/authorization information. Scans referrals received by fax and/or on paper into the appropriate section of the referral record.

Documents any communication with referring providers patients and/or Clinic (MD RN etc.) in the EHR.

Responds to incoming telephone calls regarding pending referrals and authorizations including timely response to voicemail messages.

Coordinates and provides support when scheduling all referral appointments established by practice protocols and specifically those that require prior authorization (i.e. office procedural drug etc.). Maintains current knowledge of insurer referral/authorization requirements have a working understanding of the patient population and demonstrate cultural awareness and sensitivity.

Schedules appointments according to triage guidelines. Ensures all demographics information is updated insurance verified and authorizations obtained. Notifies patients of appointment explains and educates patient to a level of understanding for the preparation needed for the upcoming appointment.

Communicates with referring providers and ensures documentation of that communication in the EHR.

Documents any and all communication with patients in the EHR. Communicates with referring providers when patients decline appointments and/or do not keep their appointments. Refers patients to the Patient Financial Advocate when necessary.

Acts as a liaison/resource with patients referring providers community providers and practice team members regarding referral issues utilizing the highest level of customer service.

Consistently monitors clinic schedules to ensure maximized scheduling and fills any available/open timeslot including those appointments cancelled and/or rescheduled.

Notifies Provider and/or Manager if unable to schedule referral need to reschedule appointment due to missing referral and/or prior authorization or if there are any other access issues.

Monitors Referral Work-Queues and ensures that all referrals have been processed accordingly.

Performs other duties as assigned including review of denials queue resolving denial and reporting to Manager any discrepancies and trends.

Other information:

EDUCATION:

High school degree or the equivalent experience

EXPERIENCE:

Two years of clinical referral and medication prior authorization experience required with at least one year of related/or at least one year of related experience in coding/billing and medical record operations in an ambulatory care facility Health Information/Medical Record Department. Demonstrated understanding of the basic functions of a therapy/treatment plan and insurance portals needed to successfully obtain prior authorizations needed for patient care. Familiarity and understanding of the content of the medical record. Spanish speaking strongly preferred. Strong organizational skills with a proven ability to prioritize and handle frequent changes in workload and able to manage competing priorities. Excellent customer service and communication skills with the ability to discuss delicate matters with patients and referring providers required. Demonstrated knowledge and skills necessary to provide care to patients through the life span with consideration of aging processes human development stages and cultural patterns in each step of the care process.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

Work is performed in a typical medical office setting requiring extensive sitting standing and walking. Reads orders for new patient appointments and medications for the majority of a day. Ability to work under fast paced sometimes stressful conditions to process new patient referrals and medication prior authorizations meeting productivity and accuracy metrics. Organized and able to manage competing priorities ability to use good judgment by showing resourcefulness in problem solving.

SUPERVISORY RESPONSIBILITY:

None

COMPETENCIES:

Understands the basic functions of a therapy/treatment plan and insurance portals needed to successfully obtain prior authorizations needed for patient care.

INDEPENDENT ACTION:

Performs independently within the department*s policies and practices. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required.

Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Rhode Island Hospital USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union