Referral & Eligibility Team Lead Job – Dallas, TX

Why You'll Love This Job

The culture at Prism Health North Texas is built on our shared Core Values:

• We are solution seekers.
• We have a can-do attitude.
• We are mission driven.
• We care about people.

Responsibilities

• Lead the new patient intake experience by guiding the team in creating a professional and welcoming environment for all new and returning patients at PHNTX, ensuring consistent, respectful, and patient-centered service.
• Oversee data quality and team development by monitoring the accurate collection and documentation of financial, insurance, demographic, and clinical data in the EMR. Provide real-time coaching and deliver ongoing training to uphold documentation standards.
• Act as the team’s insurance and eligibility resource, supporting interpretation of third-party coverage (including commercial, Medicare, Medicaid, managed care, and FFS plans) and assisting with program eligibility determination for internal support programs (e.g., Ryan White, grant-funded care, sliding-scale fees).
• Support financial access by helping the team secure authorizations and pre-certifications, determine patient responsibility, and communicate out-of-pocket costs, non-covered services, and payment options. Escalate complex coverage issues as needed.
• Direct referral coordination workflows by overseeing the timely processing of internal and external referrals across service lines. Ensure follow-up steps are completed, and communication loops are closed.
• Support the processing of specialized referrals for uninsured patients by ensuring team members complete the required documentation and follow coordination protocols for safety-net providers. Maintain and share up-to-date referral resources to assist staff in managing these workflows effectively.
• Assist with medication access workflows, including the completion of prior authorizations and coordinating with clinical and pharmacy teams to avoid care delays.
• Oversee and assist in drafting and submitting appeal and denial letters for insurance-rejected medications and services.
• Provide escalation support by resolving complex or delayed referral, scheduling, or insurance issues. Act as a liaison between patients, providers, access staff, and referral partners.
• Collaborate cross-functionally with financial navigators, case managers, and clinic leadership to proactively identify and eliminate barriers to patient care.
• Serve as a working Lead, managing direct patient-facing responsibilities (e.g., answering calls, handling walk-ins) with team coaching and oversight of referrals across PHNTX locations.
• Promote a culture of quality and accountability by modeling respectful communication, a strong work ethic, and a shared commitment to excellent, equitable care.
• Stay current on industry standards and program changes by actively participating in team meetings, training, and professional development, and sharing key updates with the team.
• Support department goals and workflow continuity by stepping in as needed to ensure efficient daily operations and uphold PHNTX’s mission of inclusive, accessible healthcare.

Skills & Qualifications

• Required Knowledge, Skills, and Abilities:
• Proficient in Microsoft Office (Word, Excel, PowerPoint, Outlook); able to track metrics and interpret basic reports.
• Experienced in navigating electronic medical records systems, preferably Athena One, and other relevant systems like CoverMyMeds and payer-specific portals.
• Experienced in peer training and workflow optimization.
• Knowledgeable in medical terminology to ensure accurate data entry and effective communication across care teams and with patients.
• Solid understanding of third-party payors (commercial insurance, Medicare, Medicaid, managed care) and eligibility programs (Ryan White, ACA); able to assist team members in interpreting benefits and gathering required documentation.
• Strong interpersonal, verbal, and written communication skills; capable of building collaborative relationships with patients, families, and multidisciplinary teams. Demonstrated team leadership through coaching, peer support, and problem-solving in dynamic clinical settings.
• Able to support care coordination decisions within role scope and contribute to smooth operations across multiple service locations by anticipating needs and facilitating team alignment.
• High School or GED required
• Associate’s degree (if no Bachelor’s) and/or relevant certification (such as CPhT, CPC/CMC, RHIA/RHIT, CHW, Certified Medical Assistant, CNA, LVN/LPN, RN) preferred.
• Certified Pharmacy Tech and/or other pharmacy experience/expertise desirable.
• 3+ years of experience in a healthcare environment handling medication prior authorizations and insurance appeals.
• Working knowledge of ICD-10, CPT coding, physician billing, and third-party reimbursement processes required.
• Previous work experience with insurance verification, prior authorizations, and/or claims processing required. Experience determining patient eligibility for public programs or assistance funding (e.g., Ryan White, Medicaid, Marketplace, or similar) strongly preferred.