Referral Specialist I

As a Referral Specialist at St. John’s Community Health, you will be responsible for managing the pre-authorization process for external referrals, including radiology referrals initiated by patients’ primary care providers. Your role is essential in ensuring timely and accurate coordination between patients, healthcare providers, and insurance companies. This position requires strong attention to detail, excellent communication skills, and a thorough understanding of medical terminology, insurance requirements, and healthcare regulations to facilitate seamless access to specialized care.

What makes a good Referral Specialist?

A Referral Specialist is detail-oriented, organized, and highly knowledgeable about medical terminology, insurance protocols, and healthcare workflows. They serve as a critical link between patients, providers, and payers, ensuring timely access to necessary medical services.

Benefits

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

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 accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education & Experience

Education: (Required)

• High School Diploma or equivalent 
• An associate's or bachelor’s degree in healthcare administration, business administration, or a related field is preferred.
• Certification as a Medical Assistant, Medical Office Specialist, or Certified Professional Coder (CPC) is a plus.

Experience: (Required)

• Minimum of 3 years of experience in healthcare administration, medical billing, or referral coordination, preferably in a high-volume clinical setting.
• Bilingual in English and Spanish preferred.
• Advanced proficiency in Microsoft Office, including Excel, Word, and Outlook, with experience generating reports and analyzing data.
• Strong knowledge of medical terminology, diagnosis codes (ICD-10), and procedure codes (CPT).
• Extensive experience with electronic health records (EHR) and practice management software; eClinicalWorks experience is a plus.
• In-depth understanding of healthcare compliance, including HIPAA, Medicare, and Medicaid guidelines.
• Strong background in insurance verification, prior authorizations, and appeals processes.
• Proven track record of providing high-level customer service and patient advocacy.
• Excellent interpersonal, verbal, and written communication skills, with the ability to liaise effectively between patients, providers, and insurance companies.
• Strong teamwork orientation with the ability to lead and train staff as needed.
• Ability to prioritize, multitask, and work independently in a fast-paced, deadline-driven environment.
• Strong analytical and problem-solving skills, with demonstrated resourcefulness and sound judgment in resolving complex referral and authorization issues.

Essential Duties And Responsibilities

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

• Receive, review, and process referral requests from healthcare providers, patients, and insurance companies with accuracy and efficiency.
• Verify patient insurance coverage, eligibility, and authorization requirements for requested services, ensuring compliance with payer guidelines.
• Assess referral requests for completeness, accuracy, and adherence to insurance and healthcare regulations.
• Work directly with physicians, specialists, and healthcare providers to gather necessary medical documentation for approval.
• Submit and track referrals through various web portals, including Medpoint Management, Optum, eConsult, Molina Direct, IEHP, and others.
• Educate providers on referral timeframes and processes to ensure compliance and timely patient care.
• Assign unassigned referrals to appropriate Referral Coordinators and evaluate workload distribution to maximize efficiency.
• Ensure compliance with all federal, state, and regulatory agency requirements related to referral management and clinical decision support.
• Meet or exceed productivity standards by processing an average of 60 external specialty referrals or 85 diagnostic imaging referrals daily.
• Modify CPT/ICD-10 codes and extend authorizations as necessary to expedite approvals.
• Process urgent referrals within 24 hours and routine referrals within 24-72 hours from the date ordered.
• Assist with resolving complex referral issues, including troubleshooting authorization delays or denials.
• Provide clear and professional communication with patients regarding referral status, required paperwork, authorizations, and appointment scheduling.
• Educate patients on the referral process, addressing any questions or concerns with empathy and professionalism.
• Ensure patients receive timely updates regarding approvals, denials, and next steps in their care.
• Assist patients in navigating insurance requirements, ensuring they understand their benefits and responsibilities.
• Act as the primary liaison between the clinic, insurance companies, and third-party payers to facilitate pre-authorization approvals.
• Stay updated on insurance policy changes, reimbursement guidelines, and regulatory updates affecting referrals.
• Troubleshoot and resolve insurance-related delays, working proactively to prevent denials.
• Escalate complex insurance issues to management or designated personnel as needed.
• Documentation and Recordkeeping.
• Maintain comprehensive and up-to-date records of all referral requests, approvals, denials, and follow-up actions in the electronic medical records (EMR) system.
• Ensure full compliance with HIPAA regulations and privacy laws when handling patient information.
• Generate referral tracking reports and assist in analyzing referral trends to optimize workflow and efficiency.
• Work closely with healthcare providers, medical staff, and administrative personnel to streamline the referral process.
• Actively participate in interdisciplinary meetings, case conferences, and training sessions to improve communication and teamwork.
• Serve as the primary clinic liaison to external agencies, healthcare networks, and specialty providers.
• Notify the Manager when all tasks are completed early and assist team members as needed to prevent referral backlogs.
• Train new staff members and educate providers on referral procedures, insurance protocols, and compliance requirements.
• Handle patient complaints related to referrals and escalated issues as necessary for resolution.
• Provide backup support to the Records team and Referral Call Center as needed.
• Work one Saturday per month or as required to ensure uninterrupted referral processing and patient support.
• Responsibilities are subject to change at the discretion of management to meet the evolving needs of the organization