Referral Coordinator

Referral Coordinator

Requirements

• H.S. diploma or G.E.D.
• 3-4 years experience in a managed care organization, hospital or physician’s office with 1 year referral experience
• Excellent medical terminology comprehension and its effective usage
• Completion of 1 Medical Terminology class with certificate of completion
• Excellent communications skills
• Computer literate
• 35 wpm keyboarding preferred
• Experience with IDX, Windows and other I.S. systems
• Good organizing skills
• Good problem-solving skills
• Ability to handle difficult calls and maintain professional conduct
• Excels as a team player
• Flexible with job responsibilities

Responsibilities

• Coordination of the Referral Process
• Collects all referrals from medical staff daily and obtains any necessary approvals from attendings.
• Works in all aspects of the referral process, including processing referrals for patients based on primary care physician orders and follow up specialists service recommended.
• Generates necessary correspondence or calls to patients, physicians and office staff, managed care organizations or vendors requesting additional information and requirements for referral authorization.
• Communicates with appropriate Physician, nursing staff and patients regarding follow-up status of referrals.
• Prepare correspondence, input referral information in the automated system, collects additional medical necessity supporting documentation and provide to appropriate parties for approval.
• Attend PHO and other vendor meetings as required to discuss changes in processing requirements.
• Identifies potential problems (i.e., labs, x-rays, procedures, and other physicians) with payment of charges from referral by communication with PHO and other managed care specialists.
• Reviews all payor requirements by type of service and organizes materials to ensure appropriate referral and that steps are followed to avoid claims denials.
• Investigates diagnosis codes and medical necessity guidelines to determine if appropriate based on payor guidelines.
• Discusses any discrepancies with physician for correct coding of referral.
• Provide correct codes both ICD9 and CPT and explains coverage to ordering physician.
• Input codes into automated system and discuss any certification requirements with vendor’s nurse certification specialist.
• Monitors approval status and resubmit request as necessary.
• Identifies need for appeal process with insurance companies and Medicare and initiates process.
• Participate in education and eligibility problem resolution.
• Works with attendings and nurses in the education of physician office staff on referral procedures.
• Acts as a resource to customers and help resolve referrals, claims and eligibility issues.
• Communication with manager, program director, other health care professionals, and various staff in a positive fashion in order to promote patient satisfaction, quality services delivered and resolution of issues.
• Verify eligibility of patients including problem resolution with Advocate MSO and various managed care organizations.
• Identifies and maintains appropriate communication with supervisor involving problems and observations in course of daily operations.
• Other duties as needed.
• Establish controls and a tickler system set-up to see if services are obtained. Maintain tracker to ensure:
• Patient received the services ordered before termination of the referral.
• Patient have proper paperwork before going to the referral site.
• Results are received from the specialist prior to the patient’s next appointment.
• Respond as needed to same day request from patient, if patient urgently needed to see a specialist or forgot paperwork.
• Assures that referral documentation is filed in the medical record and physician sees clinical results of the referrals based on a tracking system put in place.
• Collect all faxed or mailed in consultant reports for referred patients.
• Sort and place in physician mail boxes for review with patient chart.
• Assure that physician has signed off acknowledging review.
• File data in patient chart and re-file the record in the medical records file room.

Preferred Qualifications

No preferred qualifications provided.