Referral Specialist

Job Summary

The referral specialist is responsible for ensuring the timely processing of referrals for Heart of Florida Health Center patients who require special care or who may require prior authorization for necessary testing to evaluate or diagnose medical conditions.

Qualifications and Requirements

• High School diploma or equivalent

• Two (2) years of relevant work experience in patient referrals and or insurance verification is preferred

• Knowledge of medical terminology

• Experience with online referral submissions and prior authorizations for multiple payers is strongly preferred

• Bilingual preferred

Essential Functions

• Prepares and sends referrals in a timely manner.

• Maintains ongoing tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety.

• Maintains and updates Referral Management for all referrals.

• Ensures complete and accurate registration, including patient demographics and current insurance information.

• Assembles information concerning patients’ clinical backgrounds and referral needs. Per referral guidelines, provides appropriate clinical information to specialists.

• Contacts review organizations and insurance companies to ensure prior approval requirements are met. Presents necessary medical information such as history, diagnosis, and prognosis. Provides specific medical information to financial services to maximize reimbursement.

• Reviews details and expectations about the referral with patients.

• Functions as the system navigator and point of contact for patients and families, with patients and families having direct access to asking questions and raising concerns. May assume an advocate role on the patient’s behalf with the carrier to ensure approval of the necessary supplies/services for the patient in a timely fashion.

• Identifies and utilizes cultural and community resources. Establishes and maintains relationships with identified service providers.

• Reminds patients of scheduled appointments via mail or phone as appropriate.

• Notifies providers if referrals are denied and seek further instruction to proceed.

• Maintains up-to-date knowledge of insurance company requirements regarding referral authorization.

• Performs other duties as assigned by Referral Team Lead or Chief Nursing Officer.

• Responding to requests for medical records and processing letters and reports. This will be for internal workflows (such as referrals while closing the loop) or external healthcare partners

• Retrieving patient documents from system (Example: Fax inbox) and distributing to other departments electronically

• Photocopying records and documents for billing or customer service purposes, sending and receiving information via fax machine, and answering phone calls.

• Maintaining/updating patient files.

• Ensures patient charts, paperwork, and reports are completed in an accurate and timely manner.

• Keeps health care providers informed by communicating the availability of requested records.

• Maintains quality results by following guidelines and standards.

• Follows company policy and procedure for medical record release of information.

• Forwards court ordered requests for information to the Quality/Risk manager representative.

• Serves and protects the facility’s compliance to federal, state, and local guidelines.

• Performs other duties as needed.

Physical Requirements

• Frequent sitting at a desk for office work.

• Occasional driving of automobiles for outside appointments and meetings.

• Continuous use of corrected vision, depth perception, wide field of vision, and color. Also, the job will demand continuous use of olfactory, auditory, and tactile senses.

• This position is very active and requires standing, walking, bending, kneeling, and stooping all day.

• Duties require attention to detail, alertness, problem-solving, tolerance to stress, and

• exercising sound judgment

• This employee must frequently lift and/or move items over 30 pounds.

• Must be able to lift, carry and handle equipment, supplies, and other work site materials according to position requirements.