Referral Specialist

Facility

Cape Fear Valley Interventional Pain Specialists

Location

Fayetteville, North Carolina

Department

CFV Interventional Pain Specialists

Job Family

Clerical

Work Shift

Days (United States of America)

Summary

Obtains and/or verifies demographic, clinical, financial, and insurance information. Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance. Obtains and processes signed physician orders/referrals to ensure accurate clinical documentation for care delivery, specialty and outpatient ancillary referrals. In addition, the referral coordinator will conduct online insurance eligibility/benefit verification, obtain pre-certification/authorization, referral clearance and financial education on designated cases. As appropriate; notifies patient/guarantor, specialist, referring provider, etc., with pertinent information, inclusive of, but not limited to clinical documentation, referral status, follow-up, etc.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Maintains a working knowledge of the processes for medical administrative personnel, inclusive of comprehension of procedures for internal and external referrals; obtaining and sending protected patient information

• Performs insurance eligibility/benefit verification, utilizing a variety of mechanisms and ensure authorization matches test(s)/specialty from referral receipt

• Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance for service, procedure, or referral

• Obtains specialist contact information; prints orders, patient demographic, and provider letter; documents as appropriate in electronic health record (EHR)

• Determines proper referral requirements and/or limitations according to requested service, test, or procedure, to include proper identification of emergent referrals

• Pre-registers the patient for upcoming visit(s)

• Informs patient/guarantor of their liabilities, to include referral approval or denial, and documents appropriately

• Sends and/or communicates appointment confirmation to referring office, as well as calls the patient to remind of appointment date, time, location, and preparation for procedures following protocols

• Completes appropriate follow-up protocol as determined by leadership, as it relates to number of business days associated with routine and urgent referrals; initiation to completion

• Assists insurance companies, physician and physician practices, and or hospital departments with patient information in accordance with HIPAA guidelines

• Meets or exceeds accuracy standard goal determined by Patient Access Leadership

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• High school diploma or equivalent required

• Registered or Certified Medical Office Assistant OR 2 years of direct referral experience in lieu of certification required

• Licensed Practical Nurse background preferred

Work Experience: 

• 2 years insurance/referral experience within a hospital or medical office setting preferred

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language

• Knowledge of insurance and collection of payments

• Experience with Microsoft software

• Excellent verbal and written communication skills, customer service skills and problem solving abilities

• Ability to appropriately handle complexity and stress with the changing needs of the patients, families, visitors, and the Health System

• May be required to periodically rotate shifts and regular days off

• Flexibility to meet the department hours of operation

Physical Requirements: 

• Ability to communicate orally, see, and hear to collect information

• Dexterity to operate office equipment

• Subject to eyestrain due to hours spent looking at monitor screen

• Noise level is low to moderate

• Answers telephone calls

• Uses computer and other business machines extensively

• Bends, reaches, pushes and pulls file drawers to file records and reports

• Regularly lift or move up to 10 pounds, frequently lift or move up to 25 pounds and occasionally lift or move up to 50 pounds

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity