Specialist-Referral

Job Requirements

Position Summary

Referral specialists coordinates patient referrals at the request of the providers and ensures the patient''s insurance allows them to access services as ordered by their health care provider. Referral specialist handles the medical necessity review and pre-certification of services/procedures and coordinates with offices/facilities, companies, payers, financial assistance programs/resources and case managers; documenting appropriately with the medical record. The Referral Specialist will ensure appropriate coverage and medical necessity is in place, coordinate information for appointment scheduling. Provides referral follow up as needed to facilitate care coordination. Referral specialists must also work well under pressure (multitasking included) as they often deal with multiple patients in various stages of the approval process. Works with health insurance providers to determine coverage, benefit limits, and financial responsibility and conveys this information to the patient and clinical team as applicable. The Referral Specialist will provide services in areas of financial need to patients, families, and the health care team as appropriate to ease the financial hardship on patients. This position is responsible for the research of patient eligibility and access to patient assistance programs and community resources to mitigate potential financial risk to patient and organization. They must also be familiar with medical terminology in order to communicate effectively with insurance providers. Excellent written and oral communication skills are absolutely necessary. The Referral Specialist will perform patient registration tasks as appropriate to support accurate information in the medical record. Documents all stages of the referral process within the EMR program and communicates to the appropriate people regarding referral. Obtains and/or documents approvals from Payers for payment for services as directed or indicated via protocols. Answers phone calls and messages timely and acts as liaison between companies, patients, insurance companies. Requests any medical and financial information as applicable to support the referral process, documents and scans appropriate information into EMR program. The Referral Specialist has access to highly confidential information, and must handle & protect the information in accordance with hospital & system policies, HIPAA requirements and the highest level of ethical standards.

Minimum Requirements

Education

• High School Diploma or equivalent with some college or associates degree

Experience

• Minimum of five years of healthcare related experience with one of a combination of the following: patient finance, insurance benefits, financial assistance programs, public health, social services, administrative support or other health related experience
• Typing 50 words per minute minimum, HCPCS, ICD10 and/or CPT coding, knowledge of insurance, financial experience. Previous experience in Hospital/Physician''s office setting with in-depth knowledge and experience.
• Must exhibit professionalism and a desire for quality on the job performance and a desire to continuously increase their knowledge of various aspects and funding.
• Exceptional communication, conflict resolution, organization follow-up and negotiation skills. Ability to work in a high volume caseload environment required.
• Must have a pleasant, friendly, personality. Must exhibit patience, flexibility, sensitivity, and respect when dealing with public, patients, co-workers and physicians.
• Must be an effective communicator and possess a team-oriented spirit. Strives for 100 % accuracy in all assignments to support high quality patient care.
• Careful attention to detail is required to prevent errors in patient data, and reporting.

License/Registration/Certifications

• ACCC (Association of Community Cancer Centers) Boot Camp required within 1 year of employment

Preferred Requirements

Preferred Education

• Medical Billing and Coding (MBC), Medical Office Administration (MOA), Health Unit Coordinator, ACCC (Association of Community Cancer Centers) Boot Camp

Preferred Experience

• Previous experience with drug infusion billing and coding

Preferred License/Registration/Certifications

• CMC, AAPC, or CHAA

Core Job Responsibilities

• Performs patient referrals timely by completing and submitting documents and discussing with providers, insurance carriers and patients.
• Ensures patients have cleared medical necessity and authorization for specialty services (infusion/injection, diagnostic tests, referrals to other offices/facilities and specialties). This applies to scheduled and emergent patients.
• Serves as an expert in insurance verification, eligibility and medical necessity
• This person serves as a liaison between hospitals, physicians, clinical team, patients, pharmacies, vendors, referral sources, and contracted insurance plans.
• The Specialist will be instrumental in obtaining written documentation, tracking, and reporting outcomes of each authorization request.
• Resolves pre-certification case related concerns prior to patient''s appointment
• Maintain referral records documenting communication, actions, and other data in the information system
• Provides support to clinical staff in order to facilitate the administrative components of the referral
• Schedule, confirm, and communicate patient appointments as applicable
• Performs service estimates and communicates to patients.
• Performs financial screening for assistance with patients communicating indigent assistance, charity care, and copay/coinsurance assistance options and enrollment
• May assume advocate role on the patient''s behalf with the carrier to ensure approval of the necessary services for the patient in a timely fashion.
• Enters or checks patient registration demographics and makes corrections as needed.
• Responds to incoming calls regarding status from patients and insurance companies.
• Works to identify insurance trends and potential financial barriers to care and reports such issues to program administrator.
• Establishes rapport with patients by facilitating open conversation during the referral process. Consistently keeps patients abreast of any additional information related to the referral process.
• Provides education and information to co-workers and other staff as it relates to referrals.
• Assists provider in identifying appropriate network/healthcare provider to use for referrals as necessary. Referrals are made to authorized providers as specified by the insurer and/or patient requests.
• Prioritizes work to ensure that urgent referrals are handled expeditiously and routines are handled on a first come, first serve basis.
• Ensures that proper documentation is forwarded as needed and copies of documentation are retained in the patient''s medical record. Serves as a resource to patients, providers and staff to facilitate the referral process in a timely and accurate manner.
• Counsels patients on financial liability using available financial counseling tools to achieve maximum reimbursement for patient services.
• Problem Solving: Identifies, analyzes, and effectively solves problems.
• This job requires the application and interpretation of policies and procedures and the use of independent judgment in a medical setting. The individual must possess the ability to maintain a working knowledge of carrier information/changes and departmental policies and procedures.
• Must be able to operate independently to complete all tasks with minimal supervision. Must have good interpersonal skills to interact with individuals in all levels of the hospital and the public. Must have good organizational skills and be able to manage multiple tasks at the same time. Must be accountable for accuracy and timeliness of work. Must be trustworthy and committed to confidentiality. Incumbent has access to confidential hospital, patient, and financial information.