Referral Specialist

About the role

This position’s primary function is to process authorization requests timely and accurately in accordance with federal, state and accreditation guidelines. The Referral Specialist completes authorizations, including data entry of information received by phone, fax or electronically; verification of member eligibility, benefit coverage, and coordination of benefits information; communication of the members’ plan benefits and/or exclusions to physician offices; and collection of pertinent clinical documentation. The role works closely with Care Coordinators and Case Managers to provide appropriate utilization of resources, timeliness of treatment, and quality of care. The Referral Specialist provides patient communication, pre‑registration, supports scheduling appointments, and payment collection as necessary. The Referral Specialist does not make medical necessity determinations.

The incumbent works in a fast‑paced environment using telephones, email, fax, and instant messaging to respond to authorization inquiries and new requests. This position has contact with other departments and health care providers and acts as a liaison between Hometown Health, Renown, health care providers, and health insurance carriers. The individual gathers, tracks, and documents all requests received by phone, fax, mail, or electronically; manages oral and written communications related to the authorization; validates eligibility and benefit coverage to ensure requested services are authorized as covered; and keeps department leadership informed of customer opinions and viewpoints for continuous work‑process improvement. The highest standards of courteousness, performance, diplomacy, and confidentiality for patients are required.

Responsibilities

• Process authorization requests timely and accurately per federal, state, and accreditation guidelines
• Complete authorizations including data entry of information received by phone, fax, or electronically
• Verify member eligibility, benefit coverage, and coordination of benefits information
• Communicate members’ plan benefits and/or exclusions to physician offices
• Collect pertinent clinical documentation
• Collaborate with Care Coordinators and Case Managers for appropriate utilization, timeliness of treatment, and quality of care
• Provide patient communication, pre‑registration, appointment scheduling support, and payment collection as necessary
• Manage authorization requests: gather, track, and document all requests received by phone, fax, mail, or electronically
• Manage oral and written communications related to authorizations
• Validate eligibility and benefit coverage to ensure requested services are authorized as covered
• Report customer opinions and viewpoints to department leadership for continuous improvement
• Adhere to restrictions: under no circumstances perform medical necessity review activities other than review of service requests for completeness, collection/transfer of non‑clinical data (demographics, employer name, insurance information, date of surgery, physician name, facility name, etc.), acquisition of structured clinical data via medical records requests, or activities that do not require evaluation or interpretation of clinical information
• This position does not provide patient care

Skills

• Working knowledge of insurance products including HMO, PPO, Self‑funded, and Medicare Advantage plans
• Excellent written and verbal communication skills
• Ability to process large amounts of information
• Ability to work efficiently under stress and deadlines
• Knowledge of medical terminology
• Ability to assess situations, consider alternatives, and choose appropriate courses of action
• Ability to work in a fast‑paced environment with constant interruptions
• Manage multiple priorities and consistently meet department service and productivity goals
• Knowledge of ICD‑10 and CPT code diagnosis and procedures with a high level of accuracy
• Ability to organize and process work efficiently to ensure deadlines are met
• Knowledge of HIPAA and/or The Joint Commission standards

Requirements

• Education: High school graduation or GED; working‑level knowledge of the English language (reading, writing, speaking)
• Experience: At least one year working in a medical office, hospital, health care billing, or health insurance company
• License(s): None required
• Certification(s): None required
• Computer/Typing: Proficient with Microsoft Office Suite (Outlook, Excel, Word); skills to complete online learning for job‑specific competencies, access online forms and policies, complete online benefits enrollment, etc.