Referral Specialist

We're committed to bringing passion and customer focus to the business.

Job Description:

We are excited to welcome a dedicated and professional referral specialist to our team! This role is all about providing exceptional care coordination, appointment scheduling, and member advocacy while also managing internal referral processes and obtaining necessary authorizations. If you have a strong background in customer service and healthcare and thrive in a dynamic environment, we would love to hear from you!

Job location

In the Office (McAllen, TX) area, for the first 90 days upon hire date, later, job performance will be evaluated for the possibility of remote work from home.

Objectives

• Streamline care coordination between members and providers.
• Utilize community resources effectively to meet member needs.
• Enhance appropriate utilization of services and preferred providers for medical care.
• Maintain high standards of confidentiality and compliance with HIPAA regulations.

Job Responsibilities

• Maintain ongoing tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety. This tracking may use an IT database.
• Ensure complete and accurate registration, including patient demographic and current insurance information. 
• Assemble information concerning the patient's clinical background and referral needs. Per referral guidelines, provide appropriate clinical information to the specialist. 
• Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis, and prognosis. Provide specific medical information to financial services to maximize reimbursement to the hospital and physicians.
• Review details and expectations about the referral with patients.
• Assist patients in problem-solving potential issues related to the health care system, and financial or social barriers (e.g., request interpreters as appropriate, transportation services, or prescription assistance).
• Be the system navigator and point of contact for patients and families, with direct access to asking questions and raising concerns. May assume an advocate role on the patient's behalf with the carrier to ensure timely approval of the necessary supplies/services for the patient.
• Identify and utilize cultural and community resources. Establish and maintain relationships with identified service providers.
• Ensure that referrals are addressed with a high sense of urgency.
• Remind patients of scheduled appointments via mail or phone.
• Ensure that the patient's primary care chart is up to date with information on specialist consultations, hospitalizations, ER visits, and community organizations related to their health.
• Maintaining communication with referring physicians and specialists to ensure a smooth referral process and address any issues.
• Maintaining accurate records of referrals in electronic health records (EHR) systems, generating reports on referral activity and trends.

• Liaise between members and providers for care coordination, appointment scheduling, follow-up, and advocacy.
• Accurately coordinate referrals and support work prioritization.
• Identify, research, and utilize community resources appropriately.
• Complete intake assessments and use motivational interviewing to identify member needs and achieve desired outcomes.
• Develop strong relationships with members and advocate on their behalf with providers, specialists, and community agencies.
• Handle escalated members and those with high acuity and high-intensity needs.
• Act as the subject matter expert for Outreach and Referral Coordinator initiatives and report on outcomes as needed
• Complete outreach requirements and support member engagement activities.
• Participate in meetings and present information as needed.
• Run daily referral reports to create worklists and monitor referrals process.
• Research charts for supporting documents and process referrals according to departmental goals and protocols.
• Verify insurance eligibility, obtain prior authorizations and benefits from HMO eligibility lists, or by contacting insurance companies.
• Review a high volume of referral cases, enter referral information using correct coding procedures, and document referral details.
• Notify patients and referral providers of the referral process, and authorization decisions, and verify their understanding.
• Conduct periodic reviews of previously authorized ongoing care for continued need and eligibility.
• Act as a liaison for Managed Care and PCP when patients have questions.
• Serve as a clinic information source regarding managed care and referrals.
• Notify supervisors of problem referrals where turnaround goals are exceeded, or other issues are encountered.

Knowledge, Skills, and Abilities

• Ability to anticipate and solve problems promptly.
• Knowledge of local community programs, government, and social agencies.
• Ability to receive constructive feedback and take initiative to obtain training.
• Ability to multitask and prioritize multiple projects.
• Excellent verbal and written communication skills.
• Great customer service skills.
• Teamwork skills.
• Independent problem-solving skills.
• Self-motivated and self-managed.
• Detail-oriented.
• Advanced skills in Microsoft Office Suite.
• Skilled in the use of computer and EMR systems.
• Knowledge of word processing software, spreadsheet software, Internet, and database software.

Qualifications

• High school diploma or GED.
• 3-5 years of experience in customer service or related equivalent experience.
• 1-3 years of experience working in a healthcare setting.
• Previous medical referral/healthcare coordination/call center experience (preferred).
• Bilingual; fluent in English and Spanish (preferred).
• Home office (once approved), that is HIPAA compliant for all remote or telecommuting positions as outlined by company policies and procedures.
• Medical Assistant Certificate (preferred).
• Knowledge of ICD-10 and CPT-4 coding, and medical terminology.

Work Environment

• Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment.
• Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements

• Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 10 lbs.
• Close vision and ability to adjust focus.
• Must be able to work efficiently under pressure.

Additional Information

• Other duties as assigned by the supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.

We look forward to welcoming you to our team and working together to make a positive impact on our members' lives!

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!