Description

Job Objective: The Referral Specialist is responsible for verifying eligibility, checking benefits, documenting physician direct referrals, pre-authorizations of certain services, subject to the policies and procedures of Community Care of West Virginia, Inc., via phone, fax, or written requests.

Responsibilities and Essential Duties:
• Schedule, problem solve, communicate, and coordinate referral appointments with outside specialists.
• Track and enter all referral requests in the patient's electronic health record on a daily basis.
• Coordinate with primary care staff to track the status of all provider reports on patients referred to hospitals outside clinics and specialty providers and follow up for reports/records not received on referred patients.
• Maintain accurate records of external referral patient's appointments that are kept, failed, and current status in the electronic health record and follow up with the appropriate provider.
• Ensure that all referral forms are sent, including orders, medical records, appointment confirmations, etc., in a timely manner after assigned actions are completed.
• Routinely make reminder phone calls and/or send by US mail reminders to referral patients in advance of appointment with outside providers.
• Respond to in-house provider questions, requests, and concerns regarding the status of patient referrals, care coordination, or follow-up status.
• Answer, respond to, and document phone calls, requests, and questions from patients promptly. Calls must be accurately managed or redirect as appropriate
• Routinely provide patients with other hospitals, external providers, or community-based resources as appropriate.
• Handles incoming calls from physicians and members for referral authorizations of medical services. Assists CCWV physicians and staff with locating contracted providers and answering questions regarding the authorization process. All calls determined to be of clinical nature will be directed to a licensed staff member for handling.
• Verify insurance information for referral purposes and process pre-authorizations as indicated by the patient's insurance benefit.
• Comply with all departmental policies and procedures. Participate in departmental and company in-services as appropriate.
• Perform other duties as assigned by the Site Coordinator.

Patient Satisfaction:
• Assist patients, family members, or other clients with concern and empathy; respect their confidentiality and privacy; and communicate with them in a courteous and respectful manner.
• Answer and refer telephone calls or other inquires to ensure accurate and timely communications are facilitated.
• Identify yourself in a pleasant and positive manner.
• Take responsibility for helping the caller.

Teamwork:
• Consistently work in a positive and cooperative manner with fellow staff members.
• Assist other staff in the performance of their assignments.
• Demonstrate flexibility to perform duties wherever volume deems it necessary within the organization.

Problem Solving:
• Demonstrate sound judgment by taking appropriate actions regarding questionable findings or concerns.
• Investigate and follow through on unusual orders or requests for service or information.
• Follow proper reporting procedures for actual or potential accidents and/or incidents so follow-up and/or prevention can occur.
• Record/report the need for service maintenance or repair of equipment and remove any faulty equipment from service.
• Consistently evaluate work and determine if further steps are needed to meet departmental expectations.
• Ensures compliance with regulatory standards

Productivity/ Efficiency:
• Consistently demonstrate an ability to respond to changing situations in a flexible manner in order to meet current needs, such as reprioritizing work as necessary.
• Minimize non-productive time and fill slow periods with activities that will enable you to prepare to meet the organization's future needs (education, organizing, and assisting others).
• Consistently demonstrate the ability to take the initiative to make decisions/choices without direct supervision.

Adherence to Departmental Policies:
• Demonstrate knowledge and understanding of all policies and procedures and the ability to reference them from appropriate books and manuals.
• Comply with the organization's infection control policies and procedures, including Hazard Communication and OSHA Bloodborne Pathogens Standard, to ensure a safe working environment for self and others.

Qualifications

Physical Demands/Work Environment:

The physical demands described here represent those that an employee must meet to perform the essential functions of this job successfully.
• Work is performed in a professional office setting, business casual dress environment.
• Working extended hours may be required as needed.
• Extended periods of sitting and or standing, telephone work and/or computer work, as well as interactions with other staff members.
• The noise level in the work environment is usually moderate.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications/Requirements/Skills:
• Comprehensive knowledge of:
o Medical terminology
• Demonstrated ability to interact effectively and courteously with patients, physicians, providers, payors, and co-workers
• Strong analytical, organizational, and time management skills, able to work with little supervision while handling numerous projects at once.
• Deal with patient complaints and protected information in a discreet and confidential manner
• Establish rapport with the public and staff
• Maintain composure and focus in stressful situations
• Take the initiative in solving problems while using sound judgment in addressing issues
• Set and maintain work priorities

Education/Training/Experience:
• High school graduate
• At least three years of medical referral experience