Referral Administrative Auditor

Under the direction of the Director of Referral, the Referral Administrative Auditor is responsible for overseeing and auditing the Referral Management process to ensure accuracy, compliance, and efficiency. This role involves reviewing and verifying referral documentation, collecting and assessing data related to compliance with referral management procedures or process, and identifying areas for improvement in the referral workflows. The Auditor will work closely with the Director of Referrals, Referral Manager/Lead, QI Team, HealthCare providers, and insurance partners to verify the referrals are processed correctly and timely, maintaining accurate records and supporting data integrity. Additionally, the Referral Administrative Auditor may provide training, suggest process enhancements, and develop reporting tools to track referral metrics, ensuring a high standard of quality and service in patients referrals. 

Benefits:

• Free Medical, Dental & Vision
• 13 Paid Holidays PTO
• 403 (B) retirement match
• Life Insurance, EAP
• Tuition Reimbursement
• Flexible Spending Account
• Continued workforce development & training
• Succession plans & growth within

Qualifications/Licensure:    

Education Requirements: 

• College Degree in Health Administration, Health Information Management, Business, or a related field is preferred.
• Certified Professional Medical Auditor (CPMA) or Certified Healthcare Compliance (CHC) (Optional but Preferred).

Experience and Skills (Required)

• 2-3 years of experience in healthcare auditing, administration, or a related field or 8 years working in a FQHC setting preferred.
• Ability to conduct audits of patient referrals, medical records, or other clinical documentation for accuracy, compliance, and regulatory adherence.
• Proficiency in data collection and reporting tools and dashboard.
• Strong analytical skills for examining referral data, identifying compliance issues, and recommending corrective actions. 
• Familiar with Electronic Health Records (EHR) 
• Good knowledge of managed care network and healthcare regulations 
• Strong interpersonal Communication (written and verbal)
• Technical Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, Outlook
• Ability to make decisions in compliance with standards and regulations, and in alignment with organizational mission
• Adaptability and creativity
• Auditing and Analytical Skills
• Detail Orientation
• Bilingual English/Spanish preferable

Responsibilities:

Performs a combination, but not necessarily all, of the following duties:

• Conduct regular audits of all functions for Authorizations, Records, Call Center to ensure compliance with organizational guidelines and regulatory requirements.
• Identify any discrepancies, errors, or incomplete records and implement corrective actions as necessary.
• Analyze referral data to identify trends, areas for improvement and potential risk factors.
• Generate and analyze reports, particularly regarding referral patterns and compliance metrics.
• Collaborate with multidisciplinary teams, including clinical and administrative staff, to address audit findings, provide feedback, and coordinate improvements.
• Prepare and present audit reports, including any findings and recommendations for process improvements.
• Track and monitor key performance indicators (KPIs) related to referral processing and accuracy.
• Serve as a liaison between various departments (e.g. Operations, authorizations, records, call center, etc.) to ensure smooth handling of referral cases.
• Collaborate with referral coordinators, clinicians, and administrative staff to address audit findings and improve referral accuracy and compliance.
• Provide feedback and guidance to referral administrators on best practices and common audit findings.
• Ensure all referral records are accurately documented, organized, and stored in accordance with organization policies.
• Create reports for leadership on referral compliance metrics, highlighting areas for attention and recommending specific actions to enhance adherence to policies.
• Manage electronic filing systems to ensure easy access to referral documentation for audits and reporting.
• Keep records of all audits, corrective actions, and recommendations for future reference.
• Provide training sessions for referral staff on compliance standards, audit procedures and any updated practices.
• Develop and update training materials as regulations or internal procedures change.
• Recommend and participate in the development of policies and procedures to enhance the efficiency an accuracy of referral management.
• Identify process gaps and suggest improvements to streamline referral processing and audit functions.
• Maintain knowledge of current healthcare regulations and standards to ensure referrals meet all required compliance criteria.
• Train Providers and Referral Coordinators as needed
• Planning and coordinating events and conferences as needed by the Director of Referrals and Referral Manager
• May required to travel to different site locations as needed.

St. John’s Community Health is an Equal Employment Opportunity Employer