Referral Specialist-Full Time-Days

Cape Fear Valley Heart and Vascular — Dunn, NC | Clerical | Days shift

About the role

Obtains and/or verifies demographic, clinical, financial, and insurance information. Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance. Obtains and processes signed physician orders/referrals to ensure accurate clinical documentation for care delivery, specialty and outpatient ancillary referrals. Conducts online insurance eligibility/benefit verification, obtains pre-certification/authorization, referral clearance, and provides financial education on designated cases. Notifies patient/guarantor, specialist, referring provider, etc., with pertinent information including clinical documentation, referral status, and follow-up.

Responsibilities

• Maintains a working knowledge of processes for medical administrative personnel, including procedures for internal and external referrals and obtaining/sending protected patient information
• Performs insurance eligibility/benefit verification using a variety of mechanisms; ensures authorization matches test(s)/specialty from referral receipt
• Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance for service, procedure, or referral
• Obtains specialist contact information; prints orders, patient demographics, and provider letters; documents appropriately in electronic health record (EHR)
• Determines proper referral requirements and/or limitations according to requested service, test, or procedure, including proper identification of emergent referrals
• Pre-registers the patient for upcoming visit(s)
• Informs patient/guarantor of their liabilities, including referral approval or denial, and documents appropriately
• Sends and/or communicates appointment confirmation to referring office; calls patient to remind of appointment date, time, location, and preparation for procedures following protocols
• Completes appropriate follow-up protocol as determined by leadership, related to number of business days associated with routine and urgent referrals from initiation to completion
• Assists insurance companies, physician practices, and hospital departments with patient information in accordance with HIPAA guidelines
• Meets or exceeds accuracy standard goal determined by Patient Access Leadership
• Other duties as assigned

Requirements

Education & Formal Training

• High school diploma or equivalent required
• Registered or Certified Medical Office Assistant OR 2 years of direct referral experience in lieu of certification required
• Licensed Practical Nurse background preferred

Work Experience

• 2 years insurance/referral experience within a hospital or medical office setting preferred

Knowledge, Skills, & Abilities

• Proficiency in reading, writing, and speaking English
• Knowledge of insurance and collection of payments
• Experience with Microsoft software
• Excellent verbal and written communication skills, customer service skills, and problem-solving abilities
• Ability to appropriately handle complexity and stress with the changing needs of patients, families, visitors, and the Health System
• May be required to periodically rotate shifts and regular days off
• Flexibility to meet the department hours of operation

Physical Requirements

• Ability to communicate orally, see, and hear to collect information
• Dexterity to operate office equipment
• Subject to eyestrain due to hours spent looking at monitor screen
• Noise level is low to moderate
• Answers telephone calls
• Uses computer and other business machines extensively
• Bends, reaches, pushes, and pulls file drawers to file records and reports
• Regularly lift or move up to 10 pounds, frequently lift or move up to 25 pounds, and occasionally lift or move up to 50 pounds

Licenses & Certifications

• Registered or Certified Medical Office Assistant (or 2 years direct referral experience in lieu of certification)