Referral Specialist-Full Time-Days

Cape Fear Valley Health•Dunn, NC

4d•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 to ensure accurate clinical documentation for care delivery and specialty and outpatient ancillary referrals. It also performs online insurance eligibility and benefit verification, obtains pre-certification and authorization, clears referrals, and provides financial education for designated cases. As appropriate, the specialist communicates relevant information—including clinical documentation, referral status, and follow-up—to patients or guarantors, specialists, and referring providers. The position maintains knowledge of medical administrative processes, including internal and external referrals and the handling of protected patient information. It determines referral requirements and limitations, identifies emergent referrals, pre-registers patients, communicates appointment details, and completes follow-up according to established protocols. The specialist assists insurers, physicians and their practices, and hospital departments with patient information in accordance with HIPAA guidelines and meets accuracy standards set by Patient Access Leadership.

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 amid changing patient, family, visitor, and health system needs.
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 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.
Two years of insurance or referral experience in a hospital or medical office setting.

Responsibilities

Maintain working knowledge of medical administrative processes, including internal and external referrals and procedures for obtaining and sending protected patient information.
Verify insurance eligibility and benefits using available methods and ensure authorization matches the tests or specialties listed on referrals.
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.
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 approvals or denials, and document communications appropriately.
Communicate appointment confirmations to referring offices and remind patients of appointment date, time, location, and procedure preparation according to protocols.
Complete routine and urgent referral follow-up from initiation through completion according to leadership-defined timelines.
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.