Referral Specialist-Full Time-Days

Cape Fear Valley Health

5d•Onsite

About The Position

Obtains and/or verifies demographic, clinical, financial, and insurance information. Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance. Obtains and processes signed physician orders/referrals to ensure accurate clinical documentation for care delivery, specialty and outpatient ancillary referrals. In addition, the referral coordinator will conduct online insurance eligibility/benefit verification, obtain pre-certification/authorization, referral clearance and financial education on designated cases. As appropriate; notifies patient/guarantor, specialist, referring provider, etc., with pertinent information, inclusive of, but not limited to clinical documentation, referral status, follow-up, etc.

Requirements

High school diploma or equivalent required
Registered or Certified Medical Office Assistant OR 2 years of direct referral experience in lieu of certification required
Proficiency in reading, writing, and speaking the English language
Knowledge of insurance and collection of payments
Experience with Microsoft software
Excellent verbal and written communication skills, customer service skills and problem solving abilities
Ability to appropriately handle complexity and stress with the changing needs of the patients, families, visitors, and the Health System
May be required to periodically rotate shifts and regular days off
Flexibility to meet the department hours of operation
Ability to communicate orally, see, and hear to collect information
Dexterity to operate office equipment
Subject to eyestrain due to hours spent looking at monitor screen
Noise level is low to moderate
Answers telephone calls
Uses computer and other business machines extensively
Bends, reaches, pushes and pulls file drawers to file records and reports
Regularly lift or move up to 10 pounds, frequently lift or move up to 25 pounds and occasionally lift or move up to 50 pounds

Nice To Haves

Licensed Practical Nurse background preferred
2 years insurance/referral experience within a hospital or medical office setting preferred

Responsibilities

Maintains a working knowledge of the processes for medical administrative personnel, inclusive of comprehension of procedures for internal and external referrals; obtaining and sending protected patient information
Performs insurance eligibility/benefit verification, utilizing a variety of mechanisms and ensure authorization matches test(s)/specialty from referral receipt
Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance for service, procedure, or referral
Obtains specialist contact information; prints orders, patient demographic, and provider letter; documents as appropriate in electronic health record (EHR)
Determines proper referral requirements and/or limitations according to requested service, test, or procedure, to include proper identification of emergent referrals
Pre-registers the patient for upcoming visit(s)
Informs patient/guarantor of their liabilities, to include referral approval or denial, and documents appropriately
Sends and/or communicates appointment confirmation to referring office, as well as calls the patient to remind of appointment date, time, location, and preparation for procedures following protocols
Completes appropriate follow-up protocol as determined by leadership, as it relates to number of business days associated with routine and urgent referrals; initiation to completion
Assists insurance companies, physician and physician practices, and or hospital departments with patient information in accordance with HIPAA guidelines
Meets or exceeds accuracy standard goal determined by Patient Access Leadership
Other duties as assigned