Referral and Quality Specialist

POSITION SUMMARY:

The Referral and Quality Specialist is responsible for providing customers/patients with exceptional, friendly, and professional customer service experience. This role is responsible for coordinating referrals to specialty clinics by managing the referral lists, scheduling the patients, and working on follow-up items after the clinic visits take place. The position also ensures patients receive timely care by reviewing care gaps, scheduling appointments, and managing outreach through the patient engagement tools and quality platforms, while managing patient attribution to the practice.

ESSENTIAL RESPONSIBILITIES: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.

Referral Duties

• Maintain ongoing tracking and appropriate documentation of referrals to promote team awareness and ensure patient safety.
• Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis and prognosis. Provide specific medical information to financial services to maximize reimbursement to the practice.
• Review details and expectations about the referral with patients.
• Assist patients in problem solving potential issues related to the health care system, financial or social barriers.
• Ensure that referrals are addressed in a timely manner.
• Ensure that patient’s primary care chart is up to date with information on specialist consults, hospitalizations, ER visits and community organization related to their health.
• Manage documentation with a high level of accuracy and attention to detail.

Quality performance monitoring

• Track quality metrics and quality outcomes.
• Prepare actionable quality reports on a regular basis for health plans and for providers.
• Monitor trends and identify opportunities for process improvement and innovation.

Patient attribution reconciliation

• Reconcile attributed patient list from health plans with practice’s patient list.
• Partner with health plans to add and remove patients as appropriate to ensure lists reflect patients serviced by the practice, including providing appropriate outreach documentation or claims documentation of patient’s utilization activities.
• Perform outreach and assist in appointment scheduling for attributed patients who are not currently accessing primary care.

Quality gap closure

• Perform outreach and assist in appointment scheduling for patients with outstanding quality gaps.
• Build technology-enabled patient outreach campaigns for patients with outstanding quality gaps.
• Communicate recommended activities to primary care providers to enable quality gap closure at point-of-care.
• Monitor performance and collect data as needed to support quality reporting.

Other Responsibilities

• Maintain strict confidentiality; adheres to all OSHA, HIPAA, and other federal, state, and local guidelines/regulations.
• Demonstrate dedication to the mission, vision, values, and goals of the organization.
• Regular and reliable attendance including attending monthly staff meetings.
• Perform other duties as assigned.

KNOWLEDGE AND SKILLS: The requirements listed below are representative of the knowledge, skills and/or abilities required.

Education and/or Experience: High School diploma or GED required. Minimum one (1) year of referral experience, healthcare experience preferred. Medical Assistance (MA) or Licensed Practical Nurse (LPN) preferred.

Supervisory Responsibilities: No

Computer Skills / Technical Knowledge: Proficient in the use of Microsoft Office Suite and familiarity of various EMR systems. General knowledge of computer applications for the frequent use of electronic mail, word processing, data entry, spreadsheets, graphics, etc.

Mathematical Skills: Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions, decimals, and percentages. Ability to understand and identify statistical trend analysis. Ability to identify numerical trends and variances for financial analysis.

Language Skills: Ability to understand, read, write, and speak English. Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, safety data sheets (SDS) or governmental regulations. Ability to effectively present information, respond to questions and professionally interact with managers, employees, patients, vendors, the public, and diverse groups of people, particularly difficult/resistant patient populations and multiple types of providers in a variety of settings.

Reasoning Ability: Must be able to apply principles of logical thinking to define problems, collect pertinent data, establish facts, draw valid conclusions, and initiate appropriate course of action.

Other Qualifications: The ability to think critically, solve complex challenges and productively manage conflict. Must be able to handle multiple, simultaneous tasks effectively and efficiently. Strong verbal and written communication skills required. Must be detail oriented and organized with the ability to perform duties under pressure, prioritize workload, and timely meet deadlines. Must have the aptitude and ability to self-direct work.