RN Referral Reviewer

Position Summary:

The Referral Coordinator Reviewer is responsible for reviewing medical referrals to determine medical necessity and ensure compliance with CMS (Centers for Medicare & Medicaid Services) guidelines and criteria.

This role involves thorough evaluation of referral documentation, application of clinical guidelines, and collaboration with healthcare providers to facilitate appropriate patient care.

In addition, the RN Referral Coordinator Reviewer supports the Care Management (CM) team by assisting with registered nurse–designated tasks as appropriate, including completion of medication reconciliations and development and documentation of care plans for high-risk members.

Key Responsibilities:

• Review and assess medical referrals to establish medical necessity based on CMS guidelines and other guidelines.
• Apply clinical guidelines and criteria to ensure referrals meet established standards.
• Communicate with healthcare providers to obtain additional information or clarification as needed.
• Document review findings and decisions accurately in the appropriate systems.
• Collaborate with other healthcare team members to ensure coordinated and efficient patient care.
• Maintain up-to-date knowledge of CMS guidelines and criteria.
• Participate in quality improvement initiatives and training sessions.
• Ensure compliance with all regulatory and organizational policies and procedures.
• Completion of outreach and care plans for at-risk PBACO members
• Coordination of PCP follow-up visits post-ED discharge PBACO members
• Completion of post-ED medication reconciliations (to support HEDIS measure compliance) MA Members
• With the ability to undertake additional or evolving responsibilities, as needed, to support departmental and organizational priorities
  
  

Qualifications:

• RN license
• Prior experience managing referrals (preferred)
• Minimum of 2 years of experience in a clinical or healthcare setting.
• Strong understanding of CMS guidelines and criteria.
• Excellent analytical and critical thinking skills.
• Effective communication and interpersonal skills.
• Proficiency in using healthcare information systems and software.
• Strong medical knowledge and clinical background.
• Ability to work independently and as part of a team.
  
  

Physical Requirements

• Prolonged periods of sitting at a desk and working on a computer
• Must be able to lift up to 10 pounds at times
  
  

Job Type: Full-time

Schedule:

• Monday to Friday
• 8 hours shift
• No weekends
  
  

Work Location: In person

Work Remotely: No

Benefits:

• 401(k)
• Health Insurance
• Dental insurance
• Disability insurance
• Vision Insurance
• Life Insurance
• Employee assistance program
• Flexible spending account
• Paid Time Off / Holidays
  
  

Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.

This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.

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