Referral Navigator Representative - Kelsey Seybold Clinic - Utilization Review

About the role

Serves as a centralized care navigation and coordination resource within the Medical Management Department, supporting referral completion, home health services, durable medical equipment (DME) requests, call center operations, and continuity of care activities across Kelsey-Seybold Clinic and external providers. Performs initial review, triage, and validation of clinical and administrative documentation to ensure requests meet foundational criteria for authorization, physician review, and regulatory processing. Coordinates with physicians, clinics, facilities, home health agencies, providers, members, nurses, medical reviewers, and internal departments to facilitate timely progression of patient care requests and ensure complete communication throughout the continuum of care. Supports the organization's Closed the Loop program by monitoring and coordinating activities necessary to ensure members receive requested services and that all stakeholders involved in the patient's care remain informed of outcomes and next steps.

You'll enjoy the flexibility to work remotely from anywhere within the U.S.

Required Qualifications

• High School diploma or GED from an accredited program
• 2+ years of experience in a managed care, utilization management, referral management, care coordination, home health, durable medical equipment (DME), case management, medical office, hospital, health plan, accountable care organization (ACO), or healthcare operations environment
• Experience interacting with providers, physicians, clinical staff, healthcare facilities, members, and external vendors regarding healthcare services, authorizations, referrals, or care coordination activities
• Experience utilizing electronic medical records (EMR), authorization systems, payer portals, or healthcare information systems
• Proven knowledge of medical terminology, healthcare delivery systems, referral management, authorization processes, and care coordination principles
• Proven knowledge of medical terminology, CPT & ICD 10 coding, and prior authorization processes

Preferred Qualifications

• Graduate from accredited medical assistant program
• 5+ years of managed care experience either in a physician office or hospital setting, health plan, ACO, or other managed care setting
• Experience in creating authorization requests or billing Medicare or private insurance companies

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements)

Pay

The hourly pay for this role will range from $18.00 to $32.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.