Coordinator Referrals - Pediatric MFM Clinic

About the Role

This position coordinates the entire referral process for a 35-physician practice, including obtaining physician orders, securing insurance authorizations, scheduling patient appointments with in-network providers, notifying patients, and completing renewal authorizations. The role involves researching and resolving problem referral claims, ensuring appropriate physician coding and diagnoses for insurance coverage, and staying current with insurance plans, CPT, and ICD-9 coding. A clinical background is required to effectively support referrals when communicating with insurance companies. The position also educates nursing associates and physicians on changes in insurance plans affecting the referral and authorization process.

Responsibilities

• Expedite the flow of authorization requests through the Managed Care System.
• Prepare requests for authorization by ensuring form completion, eligibility verification, chart availability, and benefits.
• Accurately enter referral information into the computer system, including correct system codes, CPT codes, and ICD-9 codes.
• Coordinate Non-Subscriber Workman’s Compensation for CHRISTUS Santa Rosa and the Corporate Office to ensure proper authorization and payment.
• Facilitate documentation of authorizations into the computer system.
• Notify patients and providers of authorization decisions and maintain accurate tracking of services.
• Teach nursing associates and physicians about changes in insurance plans affecting referrals and authorizations.
• Request and print system reports for daily tasks and management reporting.
• Monitor referral flow using a tracking system to measure turnaround times and ensure timely processing.
• Notify all parties (patient, provider, requester, HMO, etc.) of authorization decisions and ensure appropriate follow-up actions.
• Distribute copies of referrals to appropriate sources and document activities in the patient’s EMR.
• Coordinate initiation of home health services, DME services, diagnostics, etc., as directed by nurses or physicians for managed care plan members.
• Serve as a resource to staff and providers regarding managed care systems, HMO/PPO benefits, and contracted providers.
• Interface with HMO/PPO patients to guide them through the referral process and explain authorization requirements.
• Provide necessary information (medical records, scripts, etc.) to payers and refer to providers for continuity of care.
• Promote and coordinate activities with payer agencies to meet provider and patient needs.
• Assist in referral research for billing and collections.
• Maintain contact with representatives of other organizations to exchange and update information on resources and services.
• Maintain compliance with federal regulations such as Anti-kickback statutes.
• Follow AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You) protocols at all times.
• Adapt responsibilities to meet the unique physical, psychosocial, cultural, and age-specific needs of patients.
• Ensure compliance with all policies, procedures, and regulatory standards.
• Protect patient confidentiality and only disclose information when necessary for job duties.
• Demonstrate adherence to the CORE values of Santa Rosa Health Care.
• Perform other duties as assigned.

Requirements

• High School Diploma or equivalent is required.
• Minimum 3 years of office experience in a healthcare setting.
• Expert knowledge of managed care benefit plans with at least 1 year of experience in a referral-based clinic or physician’s office.
• Medical assistant certification from an approved technical school is preferred.
• Experience with billing and collections for a physician office practice is required.

Skills

• Excellent customer service skills, with the ability to communicate effectively with physicians, patients, insurance companies, and staff.
• Bilingual (English and Spanish) is preferred.
• Ability to handle stress and interact with difficult patients tactfully and courteously.
• Computer literacy, including proficiency in data entry with a minimum score of 60 gross data sets per hour, 6000 keystrokes per hour, and a 2% or lower error rate.
• Strong understanding of patient confidentiality and adherence to confidentiality expectations.
• Ability to work independently with minimal supervision and follow instructions accurately.

Working Conditions

• Works in an office setting with adequate lighting and climate control.
• Requires extended periods working with a computer.
• Must successfully complete pre-employment/post-job offer health screening and annual screenings thereafter.
• Work may require flexible and/or extended hours to meet customer needs.

Schedule

8 AM – 5 PM, Monday through Friday.

Work Type

Full Time.