Referral Coordinator

About the Role

The Referral Coordinator is responsible for coordinating all referral requests and following up on all necessary documentation, certification and authorization requirements. A key responsibility is use of the automated managed care information system to process referrals.

Responsibilities

• Collects all referrals from medical staff daily and obtains any necessary approvals from attendings.
• Works in all aspects of the referral process, including processing referrals for patients based on primary care physician orders and follow up specialists service recommended.
• Generates necessary correspondence or calls to patients, physicians and office staff, managed care organizations or vendors requesting additional information and requirements for referral authorization.
• Communicates with appropriate Physician, nursing staff and patients regarding follow-up status of referrals.
• Prepares correspondence, inputs referral information in the automated system, collects additional medical necessity supporting documentation and provides to appropriate parties for approval.
• Attends PHO and other vendor meetings as required to discuss changes in processing requirements.
• Identifies potential problems (i.e., labs, x-rays, procedures, and other physicians) with payment of charges from referral by communication with PHO and other managed care specialists.
• Reviews all payor requirements by type of service and organizes materials to ensure appropriate referral and that steps are followed to avoid claims denials.
• Investigates diagnosis codes and medical necessity guidelines to determine if appropriate based on payor guidelines.
• Discusses any discrepancies with physician for correct coding of referral.
• Provides correct codes both ICD9 and CPT and explains coverage to ordering physician.
• Inputs codes into automated system and discusses any certification requirements with vendor's nurse certification specialist.
• Monitors approval status and resubmits request as necessary.
• Identifies need for appeal process with insurance companies and Medicare and initiates process.
• Works with attendings and nurses in the education of physician office staff on referral procedures.
• Acts as a resource to customers and helps resolve referrals, claims and eligibility issues.
• Communicates with manager, program director, other health care professionals, and various staff in a positive fashion in order to promote patient satisfaction, quality services delivered and resolution of issues.
• Verifies eligibility of patients including problem resolution with Advocate MSO and various managed care organizations.
• Identifies and maintains appropriate communication with supervisor involving problems and observations in course of daily operations.
• Establishes controls and a tickler system set-up to see if services are obtained. Maintains tracker to ensure:
  • Patient received the services ordered before termination of the referral.
  • Patient has proper paperwork before going to the referral site.
  • Results are received from the specialist prior to the patient's next appointment.
  • Responds as needed to same day request from patient, if patient urgently needed to see a specialist or forgot paperwork.
• Assures that referral documentation is filed in the medical record and physician sees clinical results of the referrals based on a tracking system put in place.
  • Collects all faxed or mailed in consultant reports for referred patients.
  • Sorts and places in physician mail boxes for review with patient chart.
  • Assures that physician has signed off acknowledging review.
  • Files data in patient chart and re-files the record in the medical records file room.
• Performs other duties as needed.

Requirements

• H.S. diploma or G.E.D.
• 3-4 years experience in a managed care organization, hospital or physician's office with 1 year referral experience.
• Excellent medical terminology comprehension and its effective usage.
• Completion of 1 Medical Terminology class with certificate of completion.

Qualifications

• Excellent communications skills.
• Computer literate; 35 wpm keyboarding preferred.
• Experience with IDX, Windows and other I.S. systems.
• Good organizing skills.
• Good problem-solving skills.
• Ability to handle difficult calls and maintain professional conduct.
• Excels as a team player.
• Flexible with job responsibilities.

Pay

$21.85 - $32.80

Schedule

Monday - Friday, 8 AM - 5 PM

Benefits

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program