Referral Specialist-Full Time-Days

Location: Elizabethtown, North Carolina
Department: BMA Elizabethtown
Work Shift: Days

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 medical administrative processes, including procedures for internal and external referrals and handling protected patient information
• Performs insurance eligibility/benefit verification using various mechanisms to ensure authorization matches tests/specialties from referral receipt
• Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases for clinical and financial clearance
• Obtains specialist contact information; prints orders, patient demographic information, and provider letters; documents appropriately in the electronic health record (EHR)
• Determines proper referral requirements and/or limitations according to requested service, test, or procedure, including identification of emergent referrals
• Pre-registers patients for upcoming visits
• Informs patient/guarantor of their liabilities, including referral approval or denial, and documents appropriately
• Sends/communicates appointment confirmations to referring offices and calls patients to remind them of appointment details and preparation protocols
• Completes follow-up protocols as determined by leadership, related to routine and urgent referrals from initiation to completion
• Assists insurance companies, physicians, physician practices, and hospital departments with patient information in accordance with HIPAA guidelines
• Meets or exceeds accuracy standards set by Patient Access Leadership
• Performs other duties as assigned

Requirements

• High school diploma or equivalent required
• Registered or Certified Medical Office Assistant, or 2 years of direct referral experience in lieu of certification
• Licensed Practical Nurse background preferred
• 2 years of insurance/referral experience within a hospital or medical office setting preferred

Skills

• Proficiency in reading, writing, and speaking English
• Knowledge of insurance and payment collection processes
• Experience with Microsoft software
• Excellent verbal and written communication, customer service, and problem-solving skills
• Ability to handle complexity and stress in a dynamic healthcare environment
• Flexibility to meet department hours of operation, including potential shift rotation

Physical Requirements

• Ability to communicate orally, see, and hear to collect information
• Dexterity to operate office equipment
• Subject to eyestrain due to extended monitor use
• Low to moderate noise level
• Frequent telephone use and extensive computer/business machine operation
• Bending, reaching, pushing, and pulling 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