Clinical Resource Specialist

Ohio County Healthcare•Hartford, KY

7d•Onsite

About The Position

The Clinical Resource Specialist – HMO Referral Support assists the Clinical Resource Coordinator by managing the daily execution of referral processes, including submission, tracking, and documentation of HMO referrals and authorizations. This role ensures timely processing of referrals, accurate data entry, and adherence to standardized workflows to prevent delays and claim denials.

Requirements

Minimum high school diploma or equivalent required for all positions (may be allowed to sign a GED agreement to obtain within 6 months).
Experience in medical office, scheduling, referrals, or prior authorization
Medical Assistant certification preferred (may consider experience in lieu of certification)
Strong attention to detail and accuracy
Ability to manage high-volume, repetitive tasks efficiently
Basic understanding of insurance plans and referral requirements
Strong communication and follow-up skills
EMR and computer proficiency

Nice To Haves

Medical Assistant certification

Responsibilities

Submit referral requests to primary care providers (PCPs) for HMO patients requiring specialist services
Ensure referral requests include all required clinical documentation and patient information
Verify PCP assignment on the patient’s insurance prior to submitting referrals
Assist in initiating referral orders as directed by clinic or ED workflows
Monitor status of all submitted referrals (pending, approved, denied)
Follow up with PCP offices and payers to obtain referral approvals in a timely manner
Track referral validity (visit limits and expiration dates) and notify appropriate staff when new referrals are needed
Ongoing communication with the Specialty Practices to ensure awareness of approvals and ability to schedule
Escalate delays or issues to the Clinical Resource Coordinator
Enter referral and authorization information accurately into the EMR
Upload all required referral documentation and authorization forms into the patient record
Maintain real-time status updates within the referral system (e.g., pending > approved)
Document all communications and actions taken to support audit readiness and avoid duplication
Follow standardized referral workflows and procedures established by leadership
Ensure referrals are completed prior to scheduled specialty visits to avoid claim denials
Support referral processes for clinic visits, specialty services, and ED discharge follow-ups
Assist in identifying and reporting workflow inconsistencies or gaps
Communicate with patients regarding referral status and required next steps
Assist patients with understanding PCP requirements and insurance-related questions
Coordinate with clinic staff, scheduling teams, and providers to ensure referrals are in place before appointments
Relay issues or trends that may impact patient access or scheduling
Assist in tracking referral completion and turnaround times
Identify incomplete referrals or missing documentation for correction
Support denial prevention efforts by ensuring referrals meet HMO requirements