Referral Specialist-Full Time-Days

Summary

Obtains and/or verifies demographic, clinical, financial, and insurance information. Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance. Obtains and processes signed physician orders/referrals to ensure accurate clinical documentation for care delivery, specialty and outpatient ancillary referrals. Conducts online insurance eligibility/benefit verification, obtains pre-certification/authorization, referral clearance and financial education on designated cases. Notifies patient/guarantor, specialist, referring provider, etc., with pertinent information including clinical documentation, referral status, and follow-up.

Major Job Functions

• Maintains a working knowledge of the processes for medical administrative personnel, inclusive of comprehension of procedures for internal and external referrals; obtaining and sending protected patient information
• Performs insurance eligibility/benefit verification, utilizing a variety of mechanisms and ensure authorization matches test(s)/specialty from referral receipt
• Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance for service, procedure, or referral
• Obtains specialist contact information; prints orders, patient demographic, and provider letter; documents as appropriate in electronic health record (EHR)
• Determines proper referral requirements and/or limitations according to requested service, test, or procedure, to include proper identification of emergent referrals
• Pre-registers the patient for upcoming visit(s)
• Informs patient/guarantor of their liabilities, to include referral approval or denial, and documents appropriately
• Sends and/or communicates appointment confirmation to referring office, as well as calls the patient to remind of appointment date, time, location, and preparation for procedures following protocols
• Completes appropriate follow-up protocol as determined by leadership, as it relates to number of business days associated with routine and urgent referrals; initiation to completion
• Assists insurance companies, physician and physician practices, and or hospital departments with patient information in accordance with HIPAA guidelines
• Meets or exceeds accuracy standard goal determined by Patient Access Leadership
• Other duties as assigned

Minimum Qualifications

Education and Formal Training

• High school diploma or equivalent required
• Registered or Certified Medical Office Assistant OR 2 years of direct referral experience in lieu of certification required
• Licensed Practical Nurse background preferred

Work Experience

• 2 years insurance/referral experience within a hospital or medical office setting preferred

Knowledge, Skills, and Abilities Required

• Proficiency in reading, writing, and speaking the English language
• Knowledge of insurance and collection of payments
• Experience with Microsoft software
• Excellent verbal and written communication skills, customer service skills and problem solving abilities
• Ability to appropriately handle complexity and stress with the changing needs of the patients, families, visitors, and the Health System
• May be required to periodically rotate shifts and regular days off
• Flexibility to meet the department hours of operation