Referral Specialist

Qualifications And Requirements

• High School diploma or equivalent required; Associate degree in health services, medical office administration, or related field preferred.
• Minimum two (2) years of experience in referrals, authorizations, insurance verification, or healthcare administration required.
• Knowledge of medical terminology, referral workflows, and payer requirements.
• Proficiency with Electronic Health Records (e.g., eClinicalWorks, Epic) and Microsoft Office Suite.
• Bilingual (English/Spanish/Creole) preferred, depending on patient population served.

Essential Duties And Responsibilities

• Receive, process, and document all provider-initiated referrals in the Electronic Health Record (EHR).
• Collect and assemble supporting documentation (labs, imaging, progress notes) to send with referrals.
• Verify insurance eligibility, secure prior authorizations/pre-certifications, and confirm medical necessity as required.
• Notify providers promptly of referral denials or delays and follow escalation protocols.
• Track referrals until completion, ensuring results are received and routed back to the ordering provider.
• Maintain current knowledge of referral/authorization rules.
• Retrieve and route incoming faxes, scanned documents, and electronic records to the appropriate patient chart.
• Ensure proper indexing, naming conventions, and documentation closure within the EHR.
• Maintain referral logs, reports, and supporting documentation for audit readiness.
• Respond to internal requests for records related to referrals and coordinate release-of-information activities in line with HIPAA and organizational policies.
• Forward court-ordered requests to the designated Quality/Risk representative.
• Support billing accuracy by ensuring documentation aligns with payer requirements.
• Educate patients and families about referral requirements, appointment instructions, and expectations.
• Identify and address barriers to care (transportation, financial hardship, language access, interpreter services).
• Clock in and confirm appointments with external specialists, hospitals, and diagnostic facilities.
• Follow up with patients to ensure appointments are kept and results are returned.
• Serve as a consistent point of contact for patients/families with questions or concerns related to referrals.
• Maintain collaborative relationships with community resources and partner providers.
• Adhere to HIPAA and organizational policies related to confidentiality, release of information, and documentation.
• Support HRSA, NCQA PCMH, and payer compliance requirements for referrals and continuity of care.
• Participate in audits, quality improvement projects, and departmental process evaluations.
• Contribute to organizational goals by tracking and reporting referral-related Key Performance Indicators (KPIs), including timeliness, completion rates, and patient satisfaction.

Core Competencies

• Attention to Detail: Accurate entry and management of referral and document data.
• Communication: Professional and clear interactions with patients, providers, and external partners.
• Problem-Solving: Ability to resolve barriers and adapt to complex referral or payer challenges.
• Collaboration: Works effectively with clinical staff, front desk, care coordinators, and external providers.
• Cultural Sensitivity: Demonstrates respect and responsiveness to diverse populations.
• Confidentiality: Maintains strict adherence to HIPAA and privacy rules.

Physical Requirements

• Prolonged periods of sitting, computer use, and phone work.
• Occasional standing, walking, bending, and lifting up to 30 pounds.
• Requires attention to detail, ability to multitask, and tolerance to stress in a fast-paced environment.