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.
- 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
- 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