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Primary Function:
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Under the supervision of the Practice Supervisor, the Referral Coordinator plays a crucial role between patients, referring providers, specialty and imaging practices, and insurance companies to facilitate the patient completing the requested external specialty care throughout the appointment scheduling and insurance authorization processes as needed as well as assuring that once the care has been completed and the specialty/imaging report is uploaded in the EMR for the referring provider to review and acknowledge The Referral Coordinator manages, tracks and reports on the external referrals process that provides our patients with access to external care from handling registration, obtaining insurance prior authorization, appointment scheduling and communicating to the patients’ primary care provider the results, notes, and images received (‘closing the loop’).
Key Responsibilities:
- Manage outgoing referrals created by the referring providers in the EMR’s appropriately assigned work queues in a timely manner as documented in the Standard Operating Procedures
- Coordinate and schedule patient external referral appointments while verifying demographic and financial information.
- Obtain pre-authorization from insurance carriers as indicated by the patients’ insurance coverage plans and respond to faxed, phone, and secure electronic inquiries from insurers.
- Support the department in meeting performance targets established by operational leadership.
- Facilitate communication across various stakeholders (patients, referring providers, external specialty/imaging practices, Health Information Management Department staff) between referring physicians and specialists, ensuring accurate dissemination of correspondence, between specialists and administrative office support staff.
This role is essential in ensuring that patients receive timely and efficient care, while also managing necessary administrative processes for insurance, scheduling, and interdepartmental communication.
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Duties & Responsibilities:
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- Daily manage and update assigned external referrals in the EMR workqueue for new referrals and pending referrals in the workqueue with the goal to complete the referrals in a time sensitive manner following the Standard Operating Procedures (SOP)
- Utilize EPIC to electronically send referrals to BMC to make referral appointments, review visits, and obtain labs and x-rays (according to UCC Closed Loop Process).
- Process managed care referrals/authorizations when the patient has an insurance that requires insurance prior authorization for an external specialty/imaging appointment. Once authorization is obtained, the authorization number and approved timeframe is entered in the EMR’s referral module.
- Troubleshoot complicated referrals for patients to outside specialists.
- Investigate external specialty/imaging bills or problems on behalf of patients and advocate for patients to insurance companies through dispute, grievance, and appeals processes
- On Sharepoint/intranet maintain an updated list of:
- External Specialty/Imaging Practice phone numbers, email addresses, and contact people Referral requirements.
- Insurance Provider Relations at all contracted insurances - Names, Phone, Emails
- Attend internal external meetings as needed.
- Answer questions patients may have regarding managed/accountable care: including which facility/provider to choose and the facilities UCC is affiliated with.
- Verify third-party insurance coverage for patients and verify day of service eligibility for appropriate insurance.
Referral Management
- Work cooperatively with administrative staff and providers to process external referrals for patients. Accurately document approval number, number of visits authorized, and type of service approved in the hospital registration system. Complete the paperwork for referral authorizations and submit to appropriate managed care organization in a timely manner.
- Prospectively identify patients who require authorization for specialty care and obtains appropriate provider approval prior to the appointment date. Process insurance authorizations following the insurance payor/plan’s process within the required timeframes. Enter the authorization number and approved timeframe in the EMR and share the authorization and number of visits authorized with the external specialist/imaging provider. Effectively communicate alternatives to patient if service is denied. Notify the referring provider of the insurance authorization outcome.
- Serve as a resource for clinical and administrative staff regarding managed/accountable care referrals guidelines and status of referral.
- Monitor patient flow and patient satisfaction. Prospectively identify potential issues. Trouble-shoot issues and work with Practice Supervisor to develop and implement systems to enhance efficiency.
- Follow up with patients, BMC, and other external sites for confirmation of patient attending scheduled visits.
- Confirm results, images, and notes by external specialist/imaging provider in patients’ chart. If not found in patient EMR, request results, images, and notes from external specialist/imaging provider (‘closing the loop’). If unable to secure the documentation of the completed external specialty/imaging results/visits, note this in the EMR and track this.
Scheduling
Schedule external specialty/imaging appointments following the external organization’s protocols which likely includes registering the patient if new to the external provider organization as well as scheduling. Previously identify the patient’s availability. Deal discreetly with sensitive information, always maintaining confidentiality.
- Review the following business day to finalize the schedule status and to ensure data accuracy.
- Maintain records and files, as needed. Prepare reports relative to daily schedules, as needed.
- Respond to patient phone inquiries regarding office appointments, dates of appointment
- Close referral and update scheduling status
- Reschedule patients from canceled appointments
- Facilitate urgent appointments.
Other Support Duties
- Answer telephone calls in a courteous manner, maintains department files, and responds to inquiries from internal and external providers and staff, patients, other sources, such as insurances.
- Fax or securely electronically manage patient referrals to other providers and insurance notification to insurers.
- Notify supervisor of problem(s) to ensure that it is addressed in a timely manner.
- Provide coverage to other areas under the direction of a manager and/or supervisor.
- Communicate with all members of staff on work related issues effectively and courteously.
- Assure all messages for physicians and designees are accurate and forwarded promptly to the physician and/or designee.
- Routinely handle large amounts of sensitive, confidential information and maintains confidentiality.
OTHER DUTIES:
- Perform other duties as needed.
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