Referral Reviewer

The Referral Coordinator Reviewer is responsible for reviewing medical referrals to determine medical necessity and ensure compliance with CMS (Centers for Medicare & Medicaid Services) guidelines and criteria. This role involves thorough evaluation of referral documentation, application of clinical guidelines, and collaboration with healthcare providers to facilitate appropriate patient care.

Key Responsibilities:

· Review and assess medical referrals to establish medical necessity based on CMS guidelines and other guidelines as MCG e Interqual.

· Apply clinical guidelines and criteria to ensure referrals meet established standards.

· Communicate with healthcare providers to obtain additional information or clarification as needed.

· Document review findings and decisions accurately in the appropriate systems.

· Collaborate with other healthcare team members to ensure coordinated and efficient patient care.

· Maintain up-to-date knowledge of CMS guidelines and criteria.

· Participate in quality improvement initiatives and training sessions.

· Ensure compliance with all regulatory and organizational policies and procedures.

Qualifications:

· Foreign Medical graduate. (preferred)

· Current RN or LPN

· Minimum of 2 years of experience in a clinical or healthcare setting.

· Strong understanding of CMS guidelines and criteria.

· Excellent analytical and critical thinking skills.

· Effective communication and interpersonal skills.

· Proficiency in using healthcare information systems and software.

· Strong medical knowledge and clinical background.

· Ability to work independently and as part of a team.

Working Conditions:

· Office environment with potential for remote work.

· May require occasional travel for training or meetings.


Palm is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.

This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm makes hiring decisions based solely on qualifications, merit, and business needs at the time.