Referral Coordinator Role

Under the general direction of the Director of Medical Management, the Referral Coordinator position is responsible for all referral requests. This position also serves as a liaison for customer service, claims and pharmacy.

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Essential Duties:

  • Receive incoming referrals and research for appropriate benefits, contracting provider status, and adequate supporting documentation. Notify provider if additional information is needed.
  • Enter information on submitted referral into the computer and assign referral/authorization number
  • Give processed referral to nurse managers or medical director for review, approval or denial.
  • Assists in obtaining missing or incomplete documentation for referral, IP auths, and any other requests by the nurse managers, the Medical Director, or other members of the medical team
  • Send completed referrals to ordering provider and place of service within three days of receipt
  • Update computer referral when approved by nurse manager, or denied by Medical Director.
  • Maintain high degree of accuracy and confidentiality in generating computer authorizations
  • Generate denial letters and sends to appropriate ordering provider and member. These are mailed and/or faxed within 48 hours after determination is made.
  • Receive Medical Department incoming telephone calls, assist in solving caller’s concern or relay message to appropriate staff member
  • Establish and maintain accurate tracking system for Medical Management Department within the computer system
  • Maintain strict confidentiality of medical records and secure medical records at the end of each working day
  • Shred medical documents as needed
  • Enter, verify and trouble-shoot prior authorizations for medical and pharmacy issues
  • With respect to teamwork, exhibit objectivity and openness to others’ views and help co-workers when needed; this may include cross-training with other office positions
  • Administrative denials as outlined by department protocols.
  • Auto approvals as outlined by department protocols
  • Run a daily pend list report to ensure that referrals are within compliance of the 14 day timeframe as outlined by URAC standards
  • Print and mail approval letters to members and providers on a daily basis
  • Process Early Intervention requests
  • Assist Nurse Case Manager in entering HRA documentation for our CHP+ line of business. Outreach is made to member’s family as needed.
  • Assists the claims department in obtaining needed information, makes corrections and additions as requested by claims supervisor
  • Misuse of ER letters sent to members
  • Assists in data pulls for audits
  • Works closely with the provider relations department to ensure the current provider contract information entered into the system is accurate.
  • Perform other duties as assigned

Required Knowledge, Skills & Abilities:

  • Detail oriented
  • Highly organized
  • Ability to prioritize and make routine decisions
  • Work well under pressure
  • Ability to use diplomacy in working relationships
  • Able to assess needs of a situation and act upon them without specific instructions, but within policy and procedure guidelines
  • Willing to work as part of a team

Required Education/Experience:

  • High school diploma or GED
  • 1-2 years’ experience using medical terminology and coding
  • Knowledge and understanding of Windows NT, Microsoft Word and Excel
  • Familiar with computer and basic office equipment
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