Referral Specialist-Full Time-Days

Cape Fear Valley Health

1d•Onsite

About The Position

The Referral Specialist obtains and verifies demographic, clinical, financial, and insurance information and validates medical necessity for Medicare and non-Medicare cases to support clinical and financial clearance. The role obtains and processes signed physician orders and referrals, supports accurate clinical documentation, and coordinates specialty and outpatient ancillary referrals. Duties also include online insurance eligibility and benefit verification, pre-certification and authorization, referral clearance, and financial education for designated cases. The specialist communicates relevant information—including clinical documentation, referral status, and follow-up—to patients or guarantors, specialists, and referring providers as appropriate.

Requirements

High school diploma or equivalent.
Registered or Certified Medical Office Assistant, or two years of direct referral experience in lieu of certification.
Proficiency in reading, writing, and speaking English.
Knowledge of insurance and payment collection.
Experience with Microsoft software.
Excellent verbal and written communication, customer service, and problem-solving skills.
Ability to handle complexity and stress as patient, family, visitor, and Health System needs change.
Flexibility to meet department operating hours; may be required to periodically rotate shifts and regular days off.
Ability to communicate orally, see, and hear to collect information.
Dexterity to operate office equipment.
Ability to answer telephone calls and use a computer and other business machines extensively.
Ability to bend, reach, push, and pull file drawers to file records and reports.
Ability to 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.
Two years of insurance or referral experience within a hospital or medical office setting preferred.

Responsibilities

Maintain working knowledge of medical administrative processes, including internal and external referrals and the appropriate handling and transmission of protected patient information.
Perform insurance eligibility and benefit verification using available mechanisms, and ensure authorization corresponds to the tests or specialties listed in the referral.
Validate medical necessity for Medicare and non-Medicare cases to support clinical and financial clearance for services, procedures, or referrals.
Obtain specialist contact information; print orders, patient demographics, and provider letters; and document information in the electronic health record as appropriate.
Determine referral requirements and limitations for requested services, tests, or procedures, including identifying emergent referrals.
Pre-register patients for upcoming visits.
Inform patients or guarantors of financial liabilities, including referral approval or denial, and document communications appropriately.
Communicate appointment confirmations to referring offices and call patients with appointment details and procedure preparation instructions according to protocols.
Complete follow-up according to leadership protocols and required timelines for routine and urgent referrals, from initiation through completion.
Assist insurance companies, physicians and physician practices, and hospital departments with patient information in accordance with HIPAA guidelines.
Meet or exceed accuracy standards established by Patient Access Leadership.
Perform other duties as assigned.