Referrals Specialist

About the Role

The Referral Specialist focuses on internal GMG referral processes, obtaining authorization from health plans and other utilization management entities for referrals. This role involves obtaining Local and National Coverage Determinations (LCD/NCD) from the Medical Coverage Database and communicating outcomes to patients, specialists, and other providers. The position aims to enhance appropriate utilization by directing medically necessary care to GMG services and preferred providers.

Responsibilities

• Run daily referral reports to create a work list and monitor referrals in process.
• Research charts for supporting documents and process referrals according to departmental goals and accepted protocols, including referrals from the internal GMG system, fax, and mail from health plans, specialists, and other providers.
• Verify insurance eligibility and benefits from HMO eligibility lists or by contacting insurance companies by phone when needed.
• Review a high volume of referral cases with the Chief Medical Officer (CMO) telephonically and enter referral information into the computer system using correct coding procedures (LCD/NCD).
• Document sufficient referral detail to clarify what was requested, what occurred, what was approved, and who was notified.
• Notify patients of the referral process, authorization decisions, and verify their understanding.
• Notify referral providers of authorizations in a timely manner.
• Conduct periodic reviews of previously authorized ongoing care for continued need and/or eligibility.
• Notify supervisor of problem referrals where turnaround goals are exceeded or other issues are encountered.
• Act as a liaison for Managed Care and Primary Care Physicians (PCP) when patients have questions.
• Serve as a clinic information source regarding managed care and referrals.

Requirements

• Perform all duties accurately and in a timely manner.
• Maintain clinical competencies according to Gonzaba Medical Group policy.
• Ensure customer service is always maintained at the highest level, exercising tact and courtesy when dealing with patients, visitors, providers, and co-workers.
• Adhere to customer service expectations, including in-person and virtual (via telephone or telehealth applications) communication.
• Participate in educational programs as needed.
• Bilingual English/Spanish fluency preferred.
• Maintain strictest member and company confidentiality.

Work Environment

Depending on the area assigned, the role may be in a 100% clinical setting or an office setting within a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment may occur.

Mental / Physical Requirements

• Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, and walking.
• Ability to lift up to 10 lbs.
• Close vision and ability to adjust focus.
• Must be able to work efficiently under pressure.

Additional Information

Gonzaba Medical Group seeks team members who contribute as A-Players, demonstrate a strong work ethic, and are committed to the culture and core values. Other duties may be assigned as needed.