Referral Coordinator

BrightonOne•Boston, MA

7m•$60,000 - $70,000•Hybrid

About The Position

The Patient Care Coordinator, Referral Management supports members' access to specialty and ancillary care by processing referral authorizations accurately and efficiently within a capitated, HMO-model TRICARE Prime / US Family Health Plan (USFHP) framework, keeping care in network wherever appropriate. This non-clinical role is a key point of contact for members and provider offices, coordinating the administrative components of the referral process, verifying eligibility, benefits, and network status, and ensuring a smooth, timely, and service-oriented experience for veterans and military-connected members. The Patient Care Coordinator works closely with clinical staff, recognizes when a request requires clinical review, and escalates appropriately to help members navigate the system, resolve access barriers, and close the loop on outstanding needs. The role also provides administrative support to the Utilization Management, Case and Care Management, Quality, and Clinical Operations teams as assigned. Success in the role is measured by accuracy, timeliness, compliance, and member and provider satisfaction.

Requirements

High school diploma or equivalent required
1 or more years of experience in a healthcare, health plan, or medical office setting, ideally in referrals, prior authorizations, utilization or care management support, scheduling, or member/patient services.
Experience with benefit verification and healthcare administrative workflows.
Strong customer-service orientation and professional written and verbal communication skills.
High attention to detail and accuracy in administrative processing.
Ability to navigate multiple systems simultaneously and manage a high-volume queue.
Understanding of medical terminology, HMO referral and authorization workflows, including PCP-directed referrals, in-network care, and delegated authorization authority.
Ability to recognize when a request requires clinical review and escalate appropriately.
Strong organizational and time-management skills, with the ability to balance a referral queue with administrative support tasks across multiple teams.
Proficiency with Microsoft Office and healthcare administrative systems.
Ability to work collaboratively across departments and with external partners.
High level of discretion, professionalism, and commitment to patient confidentiality.
Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.
Candidates must be authorized to work in the United States without sponsorship now or in the future.

Nice To Haves

Associate's degree or relevant post-secondary coursework preferred.
Experience within a TRICARE, USFHP, Medicare Advantage, Medicaid, or other HMO/capitated managed care organization preferred.
Experience with referral/authorization or care management platforms and knowledge of CPT/ICD coding basics preferred.
Familiarity with URAC utilization management standards and HEDIS quality measures preferred.
Familiarity with military culture and the unique needs of veterans and military-connected families preferred.

Responsibilities

Receive, review, and process referral and authorization requests for completeness, accuracy, and network appropriateness, including PCP-initiated specialty referrals, out-of-network requests, and ancillary services.
Ensure referrals are processed within DHA/TRICARE and accreditation turnaround-time requirements and notification standards, in compliance with plan policy.
Track pending referrals to resolution and follow up proactively on outstanding information.
Approve referrals that meet established administrative criteria within delegated authority, and route any request that cannot be approved administratively for clinical review; non-clinical staff do not issue medical necessity denials.
Direct referrals to contracted, in-network providers and sites of care whenever available, and flag out-of-network requests and network gaps for review in support of the plan's capitated care model.
Generate and send referral authorization notifications to members, requesting providers, and servicing providers, and manage authorization extensions, visit-count changes, and expirations.
Coordinate with Claims and Provider Relations to resolve authorization-related claim issues and discrepancies.
Verify member eligibility, benefit coverage, and network/provider status in accordance with TRICARE/USFHP requirements.
Confirm required documentation and coding is present before processing and request missing information as needed.
Identify requests requiring clinical or medical necessity review and route them promptly to Utilization Management nurse reviewers with complete supporting documentation.
Recognize urgent or expedited requests and handle them according to plan protocols.
Identify members who may benefit from case and care management, such as those with repeat, complex, or multi-specialty referral needs, and refer them to RN Case Managers.
Identify and refer potential quality-of-care concerns and potential fraud, waste, and abuse per protocol.
Serve as a courteous, responsive point of contact for members and provider offices regarding referral status and access to care.
Assist members in connecting with in-network specialists and ancillary services and help resolve access barriers.
Educate members and providers on referral and authorization requirements and processes.
Accurately document all referral activity and communications within plan systems, maintaining data integrity.
Maintain member confidentiality in compliance with HIPAA and organizational privacy policies.
Support resolution of member concerns and coordinate with internal departments to close the loop on outstanding needs.
Complete case intake and setup in the UM platform, obtain medical records and clinical information from providers, prepare determination and notification letters, and track cases against turnaround-time requirements.
Process incoming case management referrals, conduct non-clinical outreach and scheduling, and prepare member mailings and educational materials.
Support HEDIS and quality improvement activities, including medical record requests and retrieval, care-gap outreach, and data collection.
Assist in preparing case files and documentation for internal audits, inter-rater reliability activities, appeals, and DHA oversight and accreditation reviews (URAC).
Maintain trackers, logs, and reports; prepare meeting materials and minutes; update desk procedures and job aids; and support special projects as assigned.