Referral Specialist-Full Time-Days

Cape Fear Valley Health

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. Major Job Functions The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time: 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

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
2 years insurance/referral experience within a hospital or medical office setting preferred
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
Ability to communicate orally, see, and hear to collect information
Dexterity to operate office equipment

Nice To Haves

Licensed Practical Nurse background 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