Referred Care Specialist

Choctaw Nation Of Oklahoma•Talihina, OK

About The Position

The Referred Care Specialist coordinates patient referrals for external healthcare services and ensures all aspects of the Choctaw Referred Care (CRC) process are completed in alignment with organizational guidelines and federal requirements. You will support patients through scheduling, claims processing, eligibility review, denial communication, and appeals, while maintaining communication with providers and internal stakeholders. You will report to the Manager.

Requirements

Knowledge of HIPAA and Joint Commission
Two [2] years of related experience
Associate degree
Knowledge of medical terminology
Knowledge of HIPAA and Joint Commission
Two [2] years of experience
Knowledge of HIPAA and Joint Commission
Two [2] years of related experience
Process and coordinate referrals for external healthcare services by following CRC program guidelines and ensuring pre-authorization requirements are met.
Verify patient eligibility for CRC services based on descent, residency, and alternate resource requirements.
Communicate with outside providers and vendors to schedule services, obtain necessary documentation, and address claim status or authorization questions.
Support patients and families by providing guidance on the referral, denial, and appeals processes, including identifying alternate resources and explaining CRC determinations.
Review and enter referral and claim information into appropriate databases or systems to maintain accurate records.
Monitor and update CRC work queues (referrals, claims, denials, appeals) to ensure timely resolution and follow-up.
Assist with the preparation and distribution of denial letters, appeal acknowledgments, and supporting documentation for internal or external use.
Collaborate with internal departments to ensure alignment in patient care coordination and documentation compliance.
Participate in outreach or education efforts related to the CRC program, including health fairs, patient inquiries, or training sessions as assigned.
Performs other responsibilities as may be assigned.

Responsibilities

Process and coordinate referrals for external healthcare services by following CRC program guidelines and ensuring pre-authorization requirements are met.
Verify patient eligibility for CRC services based on descent, residency, and alternate resource requirements.
Communicate with outside providers and vendors to schedule services, obtain necessary documentation, and address claim status or authorization questions.
Support patients and families by providing guidance on the referral, denial, and appeals processes, including identifying alternate resources and explaining CRC determinations.
Review and enter referral and claim information into appropriate databases or systems to maintain accurate records.
Monitor and update CRC work queues (referrals, claims, denials, appeals) to ensure timely resolution and follow-up.
Assist with the preparation and distribution of denial letters, appeal acknowledgments, and supporting documentation for internal or external use.
Collaborate with internal departments to ensure alignment in patient care coordination and documentation compliance.
Participate in outreach or education efforts related to the CRC program, including health fairs, patient inquiries, or training sessions as assigned.
Performs other responsibilities as may be assigned.