Sr Referral Specialist

About the role

The Sr. Referral Specialist reports to a Patient Access Manager and ensures the quality of the referral process is upheld to departmental scheduling standards. This role is responsible for the integrity of the prior authorization processes for episode-based medication referrals, coordinating financial clearance from insurance companies, and troubleshooting as needed. The Specialist evaluates incoming referrals for accuracy and timeliness, ensuring they reflect the patient's symptoms and requested treatment.

Brown University Health employees are expected to role model the organization's values of Compassion, Accountability, Respect, and Excellence. Additionally, employees must demonstrate core Success Factors, including instilling trust, valuing differences, focusing on patients and the community, and collaborating effectively.

Responsibilities

• Receives and reviews all incoming referrals to ensure completeness and accuracy, including patient demographics, insurance eligibility, and authorizations.
• Communicates promptly with referring providers and/or patients regarding insurance coverage issues (e.g., non-participation status).
• Confirms patient eligibility with insurance carriers/third-party payors and obtains pre-authorization requirements in accordance with established medical policies.
• Coordinates and ensures appropriate insurance authorizations are obtained and/or received in a timely manner.
• Collaborates with various Brown University Health personnel to resolve billing issues, authorization denials, and insurance denials/write-offs.
• Evaluates and triages referrals by following established clinic referral guidelines to determine if additional clarification or escalation to management is needed.
• Returns incomplete/non-compliant referrals to referring physician offices with reasons for return.
• Ensures quality control of the referral process through monthly standard reports on accuracy and timeliness.
• Provides accurate and timely communication with patients, referring providers, and other staff.
• Performs at benchmarked levels related to accuracy, productivity, quality, and customer service as defined by industry standards and internal quality management.
• Coordinates and provides guidance to other staff to ensure proper documentation in the referral record.
• Assists in entering referral information into the electronic health record (EHR), including demographics, reason for referral, and insurance authorization information.
• Scans referrals received by fax or paper into the appropriate section of the referral record.
• Documents all communication with referring providers, patients, and clinic staff in the EHR.
• Responds to incoming telephone calls regarding pending referrals and authorizations, including timely responses to voicemail messages.
• Schedules appointments according to practice protocols, particularly those requiring prior authorization (e.g., office, procedural, drug).
• Maintains current knowledge of insurer referral/authorization requirements and demonstrates cultural awareness and sensitivity.
• Ensures all demographic information is updated, insurance is verified, and authorizations are obtained before scheduling.
• Notifies patients of appointments, explains preparation requirements, and documents all communication in the EHR.
• Communicates with referring providers when patients decline or miss appointments.
• Refers patients to the Patient Financial Advocate when necessary.
• Acts as a liaison/resource for patients, referring providers, community providers, and practice team members regarding referral issues.
• Monitors clinic schedules to maximize scheduling efficiency, filling available/open timeslots, including canceled or rescheduled appointments.
• Notifies providers and/or managers of scheduling issues, such as missing referrals, prior authorizations, or other access barriers.
• Monitors Referral Work-Queues to ensure all referrals are processed accordingly.
• Performs other duties as assigned, including reviewing denial queues, resolving denials, and reporting discrepancies or trends to management.

Requirements

• High school degree or equivalent experience.
• Two years of clinical referral and medication prior authorization experience, with at least one year of related experience in coding/billing and medical record operations in an ambulatory care facility or Health Information/Medical Record Department.
• Demonstrated understanding of therapy/treatment plans and insurance portals required for obtaining prior authorizations.
• Familiarity with the content of medical records.
• Strong organizational skills with the ability to prioritize and manage frequent changes in workload.
• Excellent customer service and communication skills, with the ability to discuss delicate matters with patients and referring providers.
• Demonstrated knowledge and skills to provide care to patients across the lifespan, considering aging processes, human development stages, and cultural patterns.

Work Environment

Work is performed in a typical medical office setting, requiring extensive sitting, standing, and walking. The role involves reading orders for new patient appointments and medications for the majority of the day. Ability to work under fast-paced, sometimes stressful conditions to process referrals and prior authorizations while meeting productivity and accuracy metrics. Requires resourcefulness in problem-solving and managing competing priorities.

Pay

Pay Range: $20.96 - $34.61 per hour.

Schedule

Monday through Friday, 8:30 AM to 5:00 PM. Daily hours: 8 hours.