JOB DESCRIPTION

Title:                                      Referral Management Specialist

FLSA Category:                    Non-Exempt

Reports To:                           Center Manager

Date Issued:                         June 2017, January 2025

Salary Range:                       $44,000.00 - $48,000.00

Job Summary: 

The Referral Specialist assists in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations. Interacts with patients, insurance companies, clinical staff, and outside Providers. Primary resource for arranging and scheduling authorized patient referrals. 

Essential Functions: 

1. Responsible for providing support to the clinical staff in order to facilitate administrative components of clinical referrals, prior authorizations, etc. (i.e., durable medical equipment).
2. Initiates and obtains authorization requests for outpatient services in accordance with the prior authorization list and Provider Referral Request. Verify insurance eligibility and benefits. 
3. Identifies barriers to a referral and assists in the development of breaking the barriers based on patient needs.
4. Must be able to talk and type at the same time with consistent speed and accuracy in data entry.
5. Answer telephone queues and process faxes within identified workflow and process expectations.
6. Ability to work independently as well as in a team environment supporting both clinical and non-clinical teams/staff. 
7. Collaborating with Care Coordination for intensive Managed Care Organizations (MCO) referrals as needed.
8. Possess a great attention to detail and utilize critical thinking skills to process a referral from beginning to closure.
9. Must be able to manage change and be flexible under pressure.

Nonessential Functions:

1. Excellent skills and knowledge of GE Centricity CPS12, i2i Population Health Management, and Microsoft Excel highly desired. 
2. Participates in team/staff meetings; attends in-service meetings, and applicable workshops. 
3. Perform other duties as assigned by supervisor. 

Competencies: Quality, Respect, Professionalism, Teamwork, Commitment

Supervisory Responsibility None.

Managerial Responsibilities None.

Minimum Qualifications

• High school diploma or GED equivalent required; Associate degree or Bachelor’s Degree in a related discipline preferred.

• Minimum of 2 years of experience in a healthcare setting, with referral or care coordination experience preferred.
• 1-2 years of experience in health education or related preferred. 
• 2 or more years of customer service experience preferred.

• Typing and Medical Terminology preferred.
• Bilingual English/Spanish preferred but not required. 

Competencies Needed 

Accountability – 

• Meets established expectations and takes responsibility for achieving results; encourages others to do the same.

Communication – 

• Listen and verbally in order to solve problems and provide information and direction,
• Record issues and resolutions to maintain accurate records and data for further analysis by management.

• Strong written and verbal communication skills.

• Ability to interact effectively with diverse populations, including patients, providers, and external entities

Technical Skills

• Proficiency in Electronic Health Record (EHR) systems, such as EPIC or NextGen.

• Familiarity with insurance verification, pre-authorization, and managed care guidelines

Organizational Skills –

• Time management skills to meet deadlines in a fast-paced environment.
• Exceptional attention to detail and ability to manage multiple referrals simultaneously. Effectively managing tasks and information and organize information to ensure a timely response to questions. 
• Develops and uses systems to organize and keep track of information or work progress. 

Problem Solving –

• Ability to identify and resolve barriers to care proactively

Certifications

• Medical Assistant or Certified Healthcare Access Associate (CHAA) certification is preferred, medical terminology required. 
• Bilingual skills are highly desirable.

Results Oriented – The ability to focus on the desired results, setting challenging goals, focusing effort on the goals, and meeting or exceeding them.

Time Management – Understands what is required and prioritizes to get tasks/projects completed and establishes/implements an effective course of action (ex. establishes appropriate deadlines). Reprioritizes work efforts based on changing situations and emerging issues (e.g., in response to organizational, systems, and/or schedule changes).

WorKing Conditions 

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. This office-based position with occasional patient-facing responsibilities.

Physical and Mental Demands 

1. Prolonged periods of sitting, working on a computer, and speaking on the phone.
2. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc.
3. Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.
4. The person in this position frequently communicates with patients and/or employees. Must be able to summarize and exchange accurate information.
5. Occasionally moves office equipment weighing up to 25 pounds.
6. Performs a variety of duties, often changing from one task to another.
7. Adjust priorities quickly as circumstances dictate.
8. Ability to cope with stress.
9. Ability to interact appropriately with colleagues for different purposes in different context.
10. Expressing or exchanging information to convey detailed spoken instructions accurately, loudly or quickly.
11. Ability to judge distances and spatial relationships to see objects where and as they actually are.
12. Cognitive ability to analyze, count, summarize and synthesize information from multiple sources.
13. Ability to recognize social or professional behavioral cues.

Language Skills 

Ability to read and interpret written or verbal documents and instructions. Ability to speak effectively to patients, employees and/or stakeholders of the organization.

Key Performance Indicators (KPIs)

Percentage of referrals completed within specified timeframes.

Rate of patient compliance with referral appointments.

Number of unresolved or delayed referrals.

Patient and provider satisfaction scores related to referral processes.

Travel 

Must be able to drive between Greater Baden Medical Services, Inc. locations.

This job description is subject to change based on the needs of the organization and the evolving demands of the healthcare environment.