Referral Specialist

Gary and Mary West PACE•San Marcos, CA

1d•Onsite

About The Position

The PACE Referral Specialist coordinates and processes medical, dental, and optical referrals and authorizations for care settings used by PACE participants. Reporting to the Scheduling Manager, the role uses knowledge of CPT, HCPCS, DMEPOS, and ICD-10 codes to help secure specialty services with minimal delay. The specialist works with primary care providers, clinical coordinators, specialty offices, and external providers, and uses an electronic medical record platform to prepare referrals and manage medical records. The role supports frail and chronically ill older adults in a multidisciplinary community health setting.

Requirements

High school diploma or GED equivalent.
At least one year of healthcare experience working with frail and/or chronically ill elderly people.
At least one year of experience in a healthcare setting, including front- and back-office exposure.
At least one year of experience with referral and authorization processes for managed care insurance platforms.
Excellent written and verbal communication skills, with the ability to interact clearly and effectively with internal and external customers.
Prior exposure to an electronic medical record platform.
Proficiency in Microsoft Word and Excel.
Ability to establish and maintain effective working relationships with participants, coworkers, vendors, medical staff, and the public.
Medical clearance for communicable diseases and up-to-date immunizations before direct participant contact.
Successful pre-employment drug screen, background check, and physical assessment; job offers are contingent upon these checks.

Nice To Haves

Medical Terminology Certification.
Medical Assistant Certificate.

Responsibilities

Receive and process referrals and authorizations in a timely manner.
Coordinate with primary care providers and clinical coordinators to obtain documentation for outsourced care and diagnostic or radiology services.
Communicate with specialty offices about referral and authorization status.
Use the electronic medical record platform to prepare comprehensive referrals for specialists.
Oversee obtaining, receiving, and transferring participants’ medical records to and from providers outside PACE; ensure medical release forms are complete and scan paper documents into the electronic medical record.
Conduct medical record audits as assigned.
Use clinical and administrative judgment under applicable regulations to determine appropriate approaches to urgent and non-urgent participant care needs.
Maintain HIPAA standards and comply with confidentiality policies and procedures for sensitive healthcare information.
Request additional medical records from specialty offices and clinics for review by the Utilization and Network Manager and/or PACE Medical Director as needed.
Follow departmental policies, procedures, objectives, quality assurance programs, and safety and environmental requirements.
Support professional growth by participating in educational programs, reviewing current literature, and attending in-service meetings and workshops.
Attend required meetings and participate in committees as directed.
Work flexibly and accurately, manage multiple tasks, and adapt to changing priorities in a fast-paced, high-workload environment.
Collaborate with the centralized team and maintain effective interpersonal interactions with clients in a diverse, multicultural, multidisciplinary community health setting.
Adhere to Gary and Mary West PACE core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
Perform other duties as required or requested in a positive and helpful manner.
Follow GMWP policies and procedures, safety policies and procedures, and OSHA safety guidelines.
Maintain regular attendance and punctuality.
Bring issues and process-improvement ideas to the Supervisor’s attention.
Maintain the verbal and written skills required for the position and complete annual trainings as required.
Follow the Company Dress Code Policy and demonstrate appropriate time management in support of coworkers and the team.