Job Descriptions:

Job Summary:

Spectrum Health Services, Inc. (Spectrum) is a Federally Qualified (FQHC) Health Centered Network and Level Three Patient Centered Medical Home. As a FQHC, Spectrum delivers quality care to underserved populations regardless of ability to pay. Spectrum health care teams improve the wellness outcomes of patients and populations.

Under the supervision of the Director of Operations, the Referral Specialist is responsible for managing internal and external referral processes to address clinical quality measure gaps in care. The Referral Specialist will facilitate the processing of ordered referrals utilizing the electronic medical record and health information solutions designated by Medicaid, Medicare, and Health Maintenance Organization (HMO) payer sources.

This role serves as a quality and provider liaison to ensure preauthorization requirements are met for specialty care and diagnostic referrals.

The Referral Specialist works closely with the health center Care teams to improve adherence with scheduling and keeping referral appointments. As a key member of the team, the Referral Specialist works to connect insured, indigent, uninsured and underinsured patients to referred services. This role provides support to patients, serving as a guide, advocate, and direct link to community partners and payers.

Essential Functions:

• Manages referrals in the electronic medical system from providers.

• Monitor and maintain tracking and appropriate documentation on referrals and patient authorizations to promote team awareness and ensure patient clinical quality outcomes.

• Ensure complete and accurate registration, including patient demographic and current insurance information.

• Assemble information concerning patients’ clinical background and referral needs. Per referral guidelines, provide appropriate clinical information to specialists.

• Contact review organizations and insurance companies to ensure prior approval/ preauthorization’s requirements are met. Present necessary medical information such as history, diagnosis, and prognosis. Provide specific medical information to the hospital and physicians.

• Review details and expectations about the referral with patients.

• Communicate and follow up with insurance companies to ensure all documentation proving medical necessity has been received for efficient processing.

• Communicate with patients and referring providers to ensure follow-through with referrals.

• Support doctors, staff and patients in documenting insurance requirements.

• Educate and train staff on proper referral documentation and completion.

• Assist patients in problem solving potential issues related to the health care system, financial or social barriers (ex. Request interpreters as appropriate, transportation services, or prescription assistance).

• Assist in scheduling specialist appointments.

• Collaborates with Care Management, Case Management, Outreach, and Revenue Cycle Management to improve clinical quality measure performance and patient outcomes.

• Maintains current knowledge of payer requirements and specific specialists.

• Assist patient in problem solving potential issues related to the health care system, financial or social barriers (i.e., request interpreters as appropriate, transportation services or prescription assistance)

• Be the system navigator and point of contact for patients and families, with families having direct access for asking questions and raising concerns.

• Identify and utilize cultural and community resources.

• Assume advocate role on the patient’s behalf with the insurance carrier to ensure approval of the necessary services or supplies for the patient in a timely fashion.

• Establish and maintain relationships with identified service Providers.

• Ensure that the patient stays in same healthcare system for referrals for continuity of Care Ensure referrals are addressed in a timely manner and referral loop is closed for every ordered referral in the electronic health record.

• Ensures referral consultation reports and supporting diagnostic testing results are received in a timely manner.

• Schedules primary care follow-up appointments with patients once referral reports are received.

• And other duties as assigned.

Orders Reconciliation Process:

• Contact patient to determine if the specialty appointment was kept.

• Contact specialist for consult note/test result if not received.

• Documents consultation responses and notify the patient’s ordering provider.

• Reconcile the order with the test results or consult note within 30 days for imaging and 60 days for consultations/specialty visits.

Orders Reconciliation Process continued:

• Create and manage the order tracking log using the EMR and communicate with the Provider and Care Team on a regular basis.

• Makes calls to patients regarding primary care provider's instructions for specialty follow-up care.

• Documents missed appointments.

• Notifies Social Services if a patient needs assistance.

• Order/facilitate DME as requested.

Required Experience:

Qualifications:

• High school diploma or equivalent required

• Patient Services Representative experience dealing with health insurance is preferred.

• High functioning Lead Certified Medical Assistant will be considered.

• Outpatient primary care experience is preferred.

• Experience with managing the referral process is preferred.

• Strong customer service focus

• Effective verbal and written communication skills

• Teamwork orientation

• Organized and able to manage competing priorities.

• Good judgment

• Resourcefulness in problem solving.

• Able to take and follow through with delegated tasks and accountability.

Keyword: Referral Specialist

From: Spectrum Health Services, Inc