Referral Management Specialist

Overview

Referral Management Specialist I reports to the Manager of Ambulatory Care Management. Under general supervision, the Specialist utilizes tools designed to facilitate the referral process and schedule appointments for multiple specialties for Memorial Health primary care patients. Working primarily in an office setting, the Specialist partners with the Primary Care Physician team to provide a resource for timely referrals that will increase clinical and operational processes and positively impact patient safety and quality.

The Specialist ensures timely arrangement of appointments at specialty clinics, meets primary care provider preferences when possible, meets payer requirements for referrals, completes necessary payer prior authorizations, and communicates appointment details to patients, primary care providers, and specialty offices. The Specialist follows all applicable regulations, policies, and guidelines to ensure compliant and appropriate management of patient referrals to specialty care.

Full time, day shift.

• High school diploma required.
• Certified Nursing Assistant (CNA) through state of Illinois or two years previous experience in a Primary Care Physician medical office or clinical setting required.

• Previous clerical and EHR documentation experience preferred – specifically Allscripts EHR.

• Strong knowledge of local physician networks and their associated specialties, including Springfield Clinic, SIU, OCI, Prairie and others.
• Strong general computer skills in Microsoft Office; especially Microsoft Excel spreadsheets, databases, and reporting tools strongly preferred.
• Working knowledge of insurance requirements and coverage.
• Understanding of insurance prior authorization processes and insurance referrals.
• Possesses strong medical terminology.
• Demonstrates understanding of evidence‑based healthcare.
• Demonstrates ability to work in a fast changing and ambiguous environment.
• Engaging service‑oriented skills required.
• Excellent organizational skills required; demonstrates ability to be flexible and function in stressful situations.
• Excellent oral, written communications and interpersonal skills required.
• Demonstrates initiative, self‑direction, and motivation.
• Demonstrates open/global communication skills with multiple requesters.
• Ability to work with multiple care providers and maintain positive working relationships.

• Responsible for working referrals based on various specialty procedures.
• Interacts with patients in a professional manner displaying courtesy and the ability to inform patient on procedure they will be receiving.
• Responsible for obtaining necessary referrals for patients in need of ancillary or specialty services; maintains documentation accordingly and provides authorization codes and numbers to patients; works directly with patients regarding the requirements and limitations of their health plan.
• Accountable for improving provider efficiency and effectiveness by performing referral process; allowing the care teams to spend more time with patient care.
• Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency:
  Safety—prevent harm;
  Courtesy—serve others with dignity;
  Quality—improve outcomes;
  Efficiency—reduce waste.
• Displays ability to understand insurance coverage and how to obtain pre‑authorization for procedures.
• Faxes copies of medical records to insurance companies, managed care companies and physicians’ offices to ensure that the patient’s referral will be a covered service, and that the recipient physician is prepared for the visit.
• Maintains key contacts at insurance care companies, documenting all interactions, helping to facilitate referral process.
• Acts as a primary contact when change is forthcoming with insurance coverages.
• Functions under the direction of the Supervisor, Referral Management and referring Providers.
• Must operate effectively with various levels of leadership and clinical expertise while assisting with accomplishing department goals and objectives.
• Assists team members with completion of duties in a timely and accurate manner while being able to function independently with assigned duties.
• Maintains accurate and timely documentation and follow up when applicable.
• Interacts with co‑workers, visitors, physicians and other healthcare personnel in a manner that enhances service delivery and promotes positive relationships.
• Behaves in accordance with the MHS Behavioral Standards.
• Adheres to all HIPAA guidelines and patient confidentiality policies; applies the minimum necessary standard when accessing protected health information.
• Performs opening and close of day activities, including running reports and preparing for next day’s appointments.
• Performs other related work as required or requested.