REFERRAL SPECIALIST

Description

We are an EEO employer, and all hiring practices and other terms and conditions of employment shall be maintained and conducted in a manner that ensures compliance with all applicable federal laws.

Position Summary

This position is responsible for performing duties associated with patients being referred by their Hamilton Community Health Network primary care physicians to specialists or institutions for additional health care. Understands that employment is contingent upon adherence to HCHN policies and procedures, the mission of the organization, JCAHO policies and procedures, OSHA standards and all other safety and health codes and laws.

General responsibilities

Ensures referrals are made for patients once received from the provider or the assigned MA within 24 hours of receipt of the paperwork from the provider.

Researches the patient's managed care organization plan to ensure that the referral is made to the proper provider within the patients network.

Responsible for following the guidelines as determined by each managed care plan specific to their referral process and for obtaining the appropriate authorizations. This includes:

Obtaining appropriate demographic identification for each managed care plan and utilizing specific forms/data entry as specified.

Preparing authorization with patient diagnosis and request from the primary care physician any other need information.

Responsible for faxing or mailing the authorization forms for referrals prior to the patients appointment time.

Weekly responsible for maintaining and updating their individual referral specialist log.

Maintaining the networks excel spreadsheet for every referral completed and ensuring that required data is updated.

Documenting attempts made to secure the consults as well as information regarding patients compliance with appointments.

Documenting if patient kept specialist appointment or if a second appointment is needed.

For missed appointments, the referral specialist will schedule new appointments.

Following up to ensure that consults are received for those appointments kept by requesting the consultants from the specialist if it is not received within 7 calendar days.

Tracking referrals to ensure that necessary information is obtained for the patient's chart.

Attend seminars or training sessions as appropriate for new managed care programs and/or for updates on existing programs.

Maintain up-to-date information of referral guidelines, active providers, necessary coverage information, and private insurance requirements necessary for pre-certification or outside referral as well as other related information.

Answer questions from HCHN patients requesting referral assistance and/or from referring physicians to ensure efficient patient referral and complete patient information. Questions may be related to:

Status of referral authorizations sent to the specialist.

Patient information, such as current medication list and problem lists are sent to the specialist.

Functions as the liaison with referral sources, managed care representatives, patients, and physicians concerning the network of care is overseen by primary care providers in Hamilton Community Health Network.

Mail, fax, or communicate additional, appropriate records, certificates, and authorizations to appropriate persons for the completion of the referral process as required by managed care providers.

Ability to evaluate patients response to care through observation.

Communicate with the patient to resolve issues of patient flow and at times when waiting room overflow is an issue.

Professionally handles patient complaints.

Other duties as assigned.

Qualifications

Job Requirements

Education and/or Experience

High School Diploma or G.E.D. required. Some college preferred. Previous experience working with a managed care referral process preferred. Two years clerical experience with strong secretarial/computer skills and one year experience as clinical support in a health care setting required. Must have proven knowledge of Medicaid and managed care insurance programs. Must be able to type 50 words per minute.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ability to maintain confidentiality in all matters.

Ability to provide excellent customer service skills.

Ability to use the telephone and computer.

Ability to work with the public.

Ability to meet all attendance and punctuality requirements to ensure proper coverage and quality service.

Ability to resolve interpersonal and professional conflicts appropriately.

Professional and appropriate dress as required by the position.

General computer proficiency.

Takes pride in job performance as evident in compliance with job responsibilities.

Assumes responsibility for work performance and is able to be self-directed.

Participates in staff meetings, training and committees.

Ability to communicate effectively with diverse populations.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear.

The employee frequently is required to stand, walk, sit; use hands to handle or feel; reach with hands and arms, and stoop, kneel, or crouch.

The employee must occasionally lift and/or move up to 25 pounds.

Specific vision requirements include the ability to see at close range.

Fine hand manipulation (keyboarding).

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Internal office space inside clinic area.

May be exposed to communicable diseases.

The noise level in the work environment is usually moderate.