Referral Coordinator

1 week ago

Philadelphia, Pennsylvania, United States Spectrum Health Services, Inc Full time
Job Title: Referral Specialist

Spectrum Health Services, Inc. is a Federally Qualified Health Centered Network and Level Three Patient Centered Medical Home. As a FQHC, Spectrum delivers quality care to underserved populations regardless of ability to pay.

Job Summary:

The Referral Specialist plays a critical role in managing internal and external referral processes to address clinical quality measure gaps in care. This position is responsible for facilitating the processing of ordered referrals utilizing the electronic medical record and health information solutions designated by Medicaid, Medicare, and Health Maintenance Organization (HMO) payer sources.

Key Responsibilities:
  • Manage referrals in the electronic medical system from providers.
  • Monitor and maintain tracking and appropriate documentation on referrals and patient authorizations to promote team awareness and ensure patient clinical quality outcomes.
  • Ensure complete and accurate registration, including patient demographic and current insurance information.
  • Assemble information concerning patients' clinical background and referral needs. Provide appropriate clinical information to specialists.
  • Contact review organizations and insurance companies to ensure prior approval/preauthorization requirements are met. Present necessary medical information such as history, diagnosis, and prognosis.
  • Review details and expectations about the referral with patients.
  • Communicate and follow up with insurance companies to ensure all documentation proving medical necessity has been received for efficient processing.
  • Communicate with patients and referring providers to ensure follow-through with referrals.
  • Support doctors, staff, and patients in documenting insurance requirements.
  • Educate and train staff on proper referral documentation and completion.
  • Assist patients in problem-solving potential issues related to the health care system, financial or social barriers.
  • Assist in scheduling specialist appointments.
  • Collaborate with Care Management, Case Management, Outreach, and Revenue Cycle Management to improve clinical quality measure performance and patient outcomes.
  • Maintain current knowledge of payer requirements and specific specialists.
  • Assume advocate role on the patient's behalf with the insurance carrier to ensure approval of necessary services or supplies for the patient in a timely fashion.
  • Establish and maintain relationships with identified service providers.
  • Ensure that the patient stays in the same healthcare system for referrals for continuity of care.
  • Ensure referrals are addressed in a timely manner and referral loop is closed for every ordered referral in the electronic health record.
  • Ensure referral consultation reports and supporting diagnostic testing results are received in a timely manner.
  • Schedule primary care follow-up appointments with patients once referral reports are received.
Orders Reconciliation Process:
  • Contact patient to determine if the specialty appointment was kept.
  • Contact specialist for consult note/test result if not received.
  • Document consultation responses and notify the patient's ordering provider.
  • Reconcile the order with the test results or consult note within 30 days for imaging and 60 days for consultations/specialty visits.
Requirements:
  • High school diploma or equivalent required.
  • Patient Services Representative experience dealing with health insurance is preferred.
  • High functioning Lead Certified Medical Assistant will be considered.
  • Outpatient primary care experience is preferred.
  • Experience with managing the referral process is preferred.
  • Strong customer service focus.
  • Effective verbal and written communication skills.
  • Teamwork orientation.
  • Organized and able to manage competing priorities.
  • Good judgment.
  • Resourcefulness in problem-solving.
  • Able to take and follow through with delegated tasks and accountability.
Benefits:
  • Medical.
  • Vision.
  • Dental.
  • Prescription.
  • 403b.
  • Paid Time Off/Sick.

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