Referral Coordinator Managed Care

Job Overview

Day shift: Monday - Friday: 8:30am-5pm'

This position is primarily remote with the occasional on-site requirement.

Responsible for handling all inbound calls and processing all insurance referrals for Hallmark Health PHO (HHPHO) Primary Care Physicians (PCPs). The Referral Coordinator I will follow the HHPHO referral guidelines and work with the PCPs, Medical Directors, provider’s office staff and the patient to help direct care, when medically appropriate, to a specialist within the HHPHO network and to in network services. Other responsibilities will include the support of the Patient Portal, Physician Finder Line, Rapid Access program and assistance in various projects/services within the department on an “as needed” basis.

This position coordinates all tasks associated with incoming consultation referrals from physician practices, hospitals and other healthcare facilities, as well as all benefit and referral management and medical record request management. Serves as the patient’s point of contact for medical insurance and financial counseling. The position will also report back to the multidisciplinary team.

Job Description

Minimum Qualifications:

1. High school diploma or equivalent.

2. Two (2) years of related experience in insurance, Managed Care referral processes, private physician’s office practice or hospital registration setting.

Preferred Qualifications:

1. Bachelor’s degree.

2. Three (3) years of related experience in insurance, Managed Care referral processes, private physician’s office practice or hospital registration setting.

3. MassHealth Certified Application Counselor.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

Essential Duties & Responsibilities

• Utilizes effective customer service etiquette and skills in all phases of telephone communication.
• Understands and demonstrates knowledge of basic medical terminology and diagnostic procedures.
• Maintains excellent rapport and ongoing communication with the providers, their office managers and staff.
• Maintains a basic knowledge of insurance referrals, eligibility, pre-authorizations, broad scope of benefits, subscriber vs. guarantor and order of insurance.
• Understands the various referral requirements of the different health insurance plans, including commercial and government payors.
• Processes referral requests via insurance websites as well as other systems that may be needed to submit an electronic referral and accurately enter them into the patient’s Electronic Medical Record (EMR).
• Processes referral requests via live telephone calls, fax, EMR bucket and voicemail messages.
• Learns and understands the working of the Patient Portal and can troubleshoot patient problems as needed.
• Process paper referrals for those insurance plans that do not have electronic capabilities.
• Confirm eligibility of the member being referred when necessary.
• Conveys clear and accurate documentation into patient’s referral order in EMR.
• Follows established HHPHO guidelines regarding all out of network referrals; including pending referral for review by PCP or appropriate Medical Director and educating the patient regarding referral policies and protocols.
• Communicates with PCPs to discuss possible re-direction of out of network referrals utilizing the method approved by the physician (i.e. flag, fax, etc.).
• Communicate with patients the reason for the re-direct in care and coordinate appointments with an in network specialist or service.
• Communicates with the Medical Director to review any referral request that was approved by the PCP for their patient to see an out of network specialist and reports back to Manager with results.
• Assists PCPs in processing out-of-state referrals based on the various insurance guidelines.
• Supports the Physician Finder Line.
• Supports the Rapid Access Appointment Program.
• Supports the V.P. of Managed Care, the Director, Business Services, and Central Referral Manager with special projects.

Other Duties & Responsibilities

• Assist with the daily operations of the Managed Care Department and the PHO as needed including help with mailings.
• Able to handle private patient information in a confidential and sensitive manner.
• Able to relate to and communicate effectively with persons with diverse educational, socioeconomic, gender and ethnic backgrounds
• Maintain a level of professional knowledge commensurate with industry requirements in regards to the rules of the ever changing insurance referral standards.
• Generates ideas and participates in the planning and processes to bring ideas to completion. Is willing to challenge status quo in order to improve quality.
• Communications (written and verbal) are clear, honest, and expressed in a pleasant manner, to facilitate shared decision-making and foster a learning environment.
• Listens carefully, understanding the full intent of vocabulary and nonverbal cues.
• Demonstrates ability to follow through appropriately.
• General Policies: Always complies with hospital’s policies and rules including but not limited to appropriate use of the telephone and internet, smoking and parking in designated areas, wearing ID badge, following the dress code, working scheduled hours and utilizing Kronos as instructed with minimal use of unscheduled Paid Time Off (PTO).
• Reviews disaster policies and follows in case of a disaster situation.
• Completes all other job duties as assigned.
• Performs other duties as assigned.