Clinical Resource Specialist

POSITION TITLE: 390-Clinical Resource Specialist

LOCATION: Clinical

REPORTS TO: VP of Provider Practices 

REVISION DATE: 5/19/2026

QUALIFICATIONS:

• EDUCATION: Minimum high school diploma or equivalent required for all positions (may be allowed to sign a GED agreement to obtain within 6 months).
  • REQUIRED: see above
  • PREFERRED: 
• EXPERIENCE: 
  • REQUIRED: Experience in medical office, scheduling, referrals, or prior authorization 
  • PREFERRED: 
• OTHER REQUIREMENTS OR LICENSURE: Medical Assistant certification preferred (may consider experience in lieu of certification)

• Strong attention to detail and accuracy
• Ability to manage high-volume, repetitive tasks efficiently
• Basic understanding of insurance plans and referral requirements
• Strong communication and follow-up skills
• EMR and computer proficiency

JOB DESCRIPTION: 

The job description reflects the general details considered necessary to fulfill the essential job functions and shall not be construed as all-inclusive of all work requirements inherent in this position. Other specific job-related knowledge and skills may be required. All employees subject to an annual performance evaluation based on the duties and responsibilities of this position. 

PHYSICAL DEMANDS & WORKING ENVIRONMENT: Usual working space is a well-ventilated area. Requires standing, walking, turning, bending, stooping, and lifting. Clear speech to communicate effectively with customers (e.g. patients, families, and other team members). Fine and gross motor skills. Environment may be stressful at times, therefore ability to work under stressful conditions is necessary. Lifting up to 50 lbs may be required, anything over 50 lbs should be a team lift or with the use of a lifting aid. Subject to bloodborne pathogens at all times in patient care. May have occasional exposure to radiation during radiology procedures and to dangerous chemicals (cleaning and disinfecting agents).

COMPLIANCE AND REGULATORY EXPECTATIONS: All employees are expected to conduct themselves in a manner that upholds the highest standard of integrity, ethical behavior, and regulatory compliance. As a condition of employment, employees must adhere to:

· OCH Code of Conduct

· OCH Policies and Procedures

· Scope of Practice within License/Certification.

· HIPAA and HIPAA Security Confidentiality Standards

· Workplace Safety

· Mandatory Training

· Annual Compliance Education

ESSENTIAL JOB FUNCTIONS & KEY RESPONSIBILITIES: 

The Clinical Resource Specialist – HMO Referral Support assists the Clinical Resource Coordinator by managing the daily execution of referral processes, including submission, tracking, and documentation of HMO referrals and authorizations. This role ensures timely processing of referrals, accurate data entry, and adherence to standardized workflows to prevent delays and claim denials.

Referral Submission:

• Submit referral requests to primary care providers (PCPs) for HMO patients requiring specialist services
• Ensure referral requests include all required clinical documentation and patient information
• Verify PCP assignment on the patient’s insurance prior to submitting referrals
• Assist in initiating referral orders as directed by clinic or ED workflows

Referral Tracking & Follow-Up:

• Monitor status of all submitted referrals (pending, approved, denied)
• Follow up with PCP offices and payers to obtain referral approvals in a timely manner
• Track referral validity (visit limits and expiration dates) and notify appropriate staff when new referrals are needed
• Ongoing communication with the Specialty Practices to ensure awareness of approvals and ability to schedule
• Escalate delays or issues to the Clinical Resource Coordinator

Documentation & Data Entry:

• Enter referral and authorization information accurately into the EMR
• Upload all required referral documentation and authorization forms into the patient record
• Maintain real-time status updates within the referral system (e.g., pending > approved)
• Document all communications and actions taken to support audit readiness and avoid duplication

Workflow Compliance:

• Follow standardized referral workflows and procedures established by leadership
• Ensure referrals are completed prior to scheduled specialty visits to avoid claim denials
• Support referral processes for clinic visits, specialty services, and ED discharge follow-ups
• Assist in identifying and reporting workflow inconsistencies or gaps

Patient & Staff Communication:

• Communicate with patients regarding referral status and required next steps
• Assist patients with understanding PCP requirements and insurance-related questions
• Coordinate with clinic staff, scheduling teams, and providers to ensure referrals are in place before appointments
• Relay issues or trends that may impact patient access or scheduling

Quality Support:

• Assist in tracking referral completion and turnaround times
• Identify incomplete referrals or missing documentation for correction
• Support denial prevention efforts by ensuring referrals meet HMO requirements

QUALIFICATIONS:

• EDUCATION: Minimum high school diploma or equivalent required for all positions (may be allowed to sign a GED agreement to obtain within 6 months).
  • REQUIRED: see above
  • PREFERRED: 
• EXPERIENCE: 
  • REQUIRED: Experience in medical office, scheduling, referrals, or prior authorization 
  • PREFERRED: 
• OTHER REQUIREMENTS OR LICENSURE: Medical Assistant certification preferred (may consider experience in lieu of certification)

• Strong attention to detail and accuracy
• Ability to manage high-volume, repetitive tasks efficiently
• Basic understanding of insurance plans and referral requirements
• Strong communication and follow-up skills
• EMR and computer proficiency