Referral Specialist

Referral Specialist

Department: Nursing
Reports To: Director of Nursing

Position Summary

The Referral Specialist coordinates patient referrals to specialty providers and ancillary services to ensure timely access to medically necessary care. This position works closely with providers, patients, specialists, hospitals, and insurance companies to obtain referrals, authorizations, and appointments while promoting continuity of care. The Referral Specialist serves as a resource for patients throughout the referral process and helps ensure referrals are completed accurately and efficiently.

Essential Duties and Responsibilities

• Coordinate and process referrals to specialists, diagnostic testing, and ancillary services in accordance with HCPSC policies and provider orders.
• Obtain prior authorizations and insurance approvals required for specialty services, procedures, and diagnostic testing.
• Schedule referral appointments and communicate appointment details, preparation instructions, and follow-up information to patients.
• Collaborate with providers, specialists, hospitals, and insurance companies to facilitate timely referral processing and continuity of care.
• Track referral status to ensure appointments are completed and consultation reports are received and incorporated into the patient’s Electronic Health Record (EHR).
• Verify and update patient demographic, insurance, and referral information to ensure accurate processing.
• Maintain accurate documentation of referrals, authorizations, communications, and patient follow-up activities within the Electronic Health Record (EHR).
• Respond to patient questions regarding referrals, authorizations, and specialty appointments while providing excellent customer service.
• Assist with resolving referral, insurance, and billing issues related to specialty care.
• Maintain patient confidentiality and protect health information in accordance with HIPAA and organizational policies.
• Participate in required trainings, staff meetings, and quality improvement initiatives.
• Perform other duties as assigned.

Education & Experience

• High school diploma or equivalent required.
• Certified Medical Assistant (CMA or CCMA) certification preferred but not required.
• Minimum of two (2) years of experience in referral coordination, medical office operations, patient access, care coordination, or a related healthcare setting preferred.
• Experience obtaining prior authorizations, insurance verification, or coordinating specialty referrals preferred.
• Experience working in a Federally Qualified Health Center (FQHC) or community health center preferred.
• Experience using Electronic Health Record (EHR) systems preferred.

Knowledge, Skills, and Abilities

• Knowledge of referral coordination, prior authorization processes, insurance verification, and medical terminology.
• Knowledge of HIPAA regulations and the ability to maintain the confidentiality, security, and integrity of patient information.
• Strong organizational, communication, and customer service skills with the ability to manage multiple priorities in a fast-paced healthcare environment.
• Proficiency in Microsoft Office and Electronic Health Record (EHR) systems.
• Ability to collaborate effectively with providers, specialists, hospitals, insurance companies, and interdisciplinary healthcare teams.

• Ability to exercise sound judgment, solve problems effectively, and maintain accurate documentation.