Referral & Eligibility Team Lead

Job Description

Job Description

Our Core Values:
The culture at Prism Health North Texas is built on our shared Core Values. We make hiring, firing, promotion, and performance review decisions based on these values and behaviors, so it is important that you also share these Core Values:

• We are solution seekers.
• We have a can-do attitude.
• We are mission driven.
• We care about people.

The Patient Referral & Eligibility Team Lead (“Lead”) ensures effective coordination of new patient intake, insurance verification, and scheduling; inbound, outbound, internal, and external referrals; and medication prior authorizations. The Lead provides day-to-day organization, support, training, and guidance to team members, promotes accurate documentation, program eligibility determination, and consistent communication workflows. With a deep understanding of insurance and referral processes, the Lead focuses on closing the loop on referrals and prior authorizations, ensuring timely follow-up, resolving access barriers, and maintaining continuity of care. By streamlining operations and enhancing service delivery, this position supports PHNTX’s mission to provide equitable, patient-centered access to healthcare.

• Lead the new patient intake experience by guiding the team in creating a professional and welcoming environment for all new and returning patients at PHNTX, ensuring consistent, respectful, and patient-centered service.
• Oversee data quality and team development by monitoring the accurate collection and documentation of financial, insurance, demographic, and clinical data in the EMR. Provide real-time coaching and deliver ongoing training to uphold documentation standards.
• Act as the team’s insurance and eligibility resource, supporting interpretation of third-party coverage (including commercial, Medicare, Medicaid, managed care, and FFS plans) and assisting with program eligibility determination for internal support programs (e.g., Ryan White, grant-funded care, sliding-scale fees).
• Support financial access by helping the team secure authorizations and pre-certifications, determine patient responsibility, and communicate out-of-pocket costs, non-covered services, and payment options. Escalate complex coverage issues as needed.
• Direct referral coordination workflows by overseeing the timely processing of internal and external referrals across service lines. Ensure follow-up steps are completed, and communication loops are closed.
• Support the processing of specialized referrals for uninsured patients by ensuring team members complete the required documentation and follow coordination protocols for safety-net providers. Maintain and share up-to-date referral resources to assist staff in managing these workflows effectively.
• Assist with medication access workflows, including the completion of prior authorizations and coordinating with clinical and pharmacy teams to avoid care delays.
• Oversee and assist in drafting and submitting appeal and denial letters for insurance-rejected medications and services.
• Provide escalation support by resolving complex or delayed referral, scheduling, or insurance issues. Act as a liaison between patients, providers, access staff, and referral partners.
• Collaborate cross-functionally with financial navigators, case managers, and clinic leadership to proactively identify and eliminate barriers to patient care.  
• Serve as a working Lead, managing direct patient-facing responsibilities (e.g., answering calls, handling walk-ins) with team coaching and oversight of referrals across PHNTX locations. 
• Promote a culture of quality and accountability by modeling respectful communication, a strong work ethic, and a shared commitment to excellent, equitable care. 
• Stay current on industry standards and program changes by actively participating in team meetings, training, and professional development, and sharing key updates with the team. 
• Support department goals and workflow continuity by stepping in as needed to ensure efficient daily operations and uphold PHNTX’s mission of inclusive, accessible healthcare.

• Required Knowledge, Skills, and Abilities:

• Proficient in Microsoft Office (Word, Excel, PowerPoint, Outlook); able to track metrics and interpret basic reports.
• Experienced in navigating electronic medical records systems, preferably Athena One, and other relevant systems like CoverMyMeds and payer-specific portals. 
• Experienced in peer training and workflow optimization.
• Knowledgeable in medical terminology to ensure accurate data entry and effective communication across care teams and with patients.
• Solid understanding of third-party payors (commercial insurance, Medicare, Medicaid, managed care) and eligibility programs (Ryan White, ACA); able to assist team members in interpreting benefits and gathering required documentation.
• Strong interpersonal, verbal, and written communication skills; capable of building collaborative relationships with patients, families, and multidisciplinary teams. Demonstrated team leadership through coaching, peer support, and problem-solving in dynamic clinical settings.
• Able to support care coordination decisions within role scope and contribute to smooth operations across multiple service locations by anticipating needs and facilitating team alignment.

• High School or GED required
• Associate’s degree (if no Bachelor’s) and/or relevant certification (such as CPhT, CPC/CMC, RHIA/RHIT, CHW, Certified Medical Assistant, CNA, LVN/LPN, RN) preferred.
• Certified Pharmacy Tech and/or other pharmacy experience/expertise desirable.
• 3+ years of experience in a healthcare environment handling medication prior authorizations and insurance appeals.
• Working knowledge of ICD-10, CPT coding, physician billing, and third-party reimbursement processes required.
• Previous work experience with insurance verification, prior authorizations, and/or claims processing required. Experience determining patient eligibility for public programs or assistance funding (e.g., Ryan White, Medicaid, Marketplace, or similar) strongly preferred.
• The successful candidate will demonstrate critical thinking, problem-solving, attendance/reliability, and communication skills. The successful candidate will demonstrate a high level of rigor and accuracy, flexibility, eagerness to learn, accountability, and will work collaboratively and effectively as part of a multidisciplinary team.