Referral Coordinator

Bakersfield Family Medical Group•Templeton, CA

6d•$24 - $29

About The Position

Under the direction of the Clinic Supervisor, the Referral Coordinator verifies and interprets member benefits for health plans. The role interacts professionally and courteously with other departments, clinic personnel, and outside providers to maintain positive relationships with internal and external customers. The position supports the utilization management prior authorization and referral process, including eligibility and benefit verification, referral preparation and review, provider coordination, accurate data entry, and compliance with health plan and CMS timelines and regulations. It also maintains documentation and filing, communicates issues to management, and provides coverage as needed.

Requirements

High school graduate or GED certification.
At least one year of experience in a medical office environment; prior authorization experience is required.
Knowledge of medical terminology.
Knowledge of HCPC, CPT, and ICD-10.
Proficient written and oral communication skills.
Proficiency with the computer systems used for the role.
Ability to stay organized and manage competing priorities.
Good judgment.
Ability to accept and follow through on delegated tasks and be accountable.
Resourcefulness in problem-solving.

Nice To Haves

Experience in an IPA or HMO medical office environment is preferred.

Responsibilities

Use utilization management prior authorization systems efficiently.
Verify eligibility and interpret benefits through health plan and Medicare (CMS) websites.
Serve as a resource for providers with questions about network specialists.
Prepare authorizations and refer members to appropriate providers, facilities, and durable medical equipment (DME) companies.
Coordinate and communicate with physician offices, processing staff, and other departments to support collaboration throughout the referral process; respond to messages by the next business day.
Review pending referrals prepared by Authorization Clerk staff for accuracy of ICD-10, CPT, HCPC codes, and provider selections.
Ensure referral information is accurately entered into utilization management systems based on submitted referral and clinical information.
Understand and follow established Heritage provider network authorization policies and procedures.
Perform assigned duties to an acceptable standard and inform management daily when problems arise or work falls behind.
Document good-faith attempts to obtain medical records for pending referrals with missing information.
Compile clinical guidelines, criteria, and benefit information before forwarding referrals to UM Managers for clinical review.
Maintain filing in a timely manner and provide Referral Coordinator coverage as needed.
Process referrals on daily trending reports to comply with health plan and CMS timeframe regulations.
Follow health plan and CMS requirements for timelines, benefits, and guideline hierarchy, and adapt to regulatory and departmental procedure changes affecting prior authorization processes.
Comply with HIPM regulations and maintain patient confidentiality.
Complete cultural and linguistics training annually.
Perform other duties as assigned.