Referral Coordinator

American Addiction Centers•Elkin, NC

1d•Onsite

About The Position

The Referral Coordinator is responsible for managing the referral process for patients, ensuring that all necessary steps are followed for authorizations and that patients receive the ordered services. This role involves daily collection and processing of referrals, generating correspondence, communicating with patients and providers, and investigating payor requirements to prevent claims denials. The coordinator also participates in education and problem resolution, acts as a resource for referral and claims issues, and maintains tracking systems to ensure services are obtained and results are received.

Requirements

H.S. diploma or G.E.D.
3-4 years experience in a managed care organization, hospital, or physician’s office with 1 year referral experience
Excellent medical terminology comprehension and its effective usage
Completion of 1 Medical Terminology class with certificate of completion.
Excellent communications skills.
Computer literate
Experience with IDX, Windows and other I.S. systems
Good organizing skills.
Good problem-solving skills
Ability to handle difficult calls and maintain professional conduct
Excels as a team player
Flexible with job responsibilities
Ability to work independently.
Ability to handle stress and high workload volumes.
Ability to communicate denial of services to members and providers.
Ability to lift up to 35 pounds without assistance.

Nice To Haves

35 wpm keyboarding preferred

Responsibilities

Collects all referrals from medical staff daily and obtains any necessary approvals from attendings.
Processes referrals for patients based on primary care physician orders and follow-up specialist services recommended.
Generates necessary correspondence or calls to patients, physicians, office staff, managed care organizations, or vendors requesting additional information and requirements for referral authorization.
Communicates with appropriate Physician, nursing staff, and patients regarding follow-up status of referrals.
Prepares correspondence, inputs referral information in the automated system, collects additional medical necessity supporting documentation, and provides it to appropriate parties for approval.
Attends PHO and other vendor meetings as required to discuss changes in processing requirements.
Identifies potential problems with payment of charges from referral by communication with PHO and other managed care specialists.
Reviews all payor requirements by type of service and organizes materials to ensure appropriate referral and that steps are followed to avoid claims denials.
Investigates diagnosis codes and medical necessity guidelines to determine if appropriate based on payor guidelines.
Discusses any discrepancies with physician for correct coding of referral.
Provides correct codes (ICD9 and CPT) and explains coverage to ordering physician.
Inputs codes into automated system and discusses any certification requirements with vendor’s nurse certification specialist.
Monitors approval status and resubmits requests as necessary.
Identifies need for appeal process with insurance companies and Medicare and initiates process.
Works with attendings and nurses in the education of physician office staff on referral procedures.
Acts as a resource to customers and helps resolve referrals, claims, and eligibility issues.
Communicates with manager, program director, other health care professionals, and various staff in a positive fashion to promote patient satisfaction, quality services delivered, and resolution of issues.
Verifies eligibility of patients, including problem resolution with Advocate MSO and various managed care organizations.
Identifies and maintains appropriate communication with supervisor involving problems and observations in the course of daily operations.
Performs other duties as needed.
Establishes controls and a tickler system to track if services are obtained.
Maintains a tracker to ensure patients receive services ordered before referral termination, have proper paperwork before going to the referral site, and results are received from the specialist prior to the patient’s next appointment.
Responds as needed to same-day requests from patients for urgent specialist appointments or forgotten paperwork.
Assures that referral documentation is filed in the medical record and that physicians review clinical results of referrals based on a tracking system.
Collects all faxed or mailed consultant reports for referred patients.
Sorts and places consultant reports in physician mailboxes for review with patient charts.
Assures that the physician has signed off acknowledging review of consultant reports.
Files data in patient charts and re-files the record in the medical records file room.