Referral Specialist

Referral Specialist

Under the direction supervision of the Scheduling Manager, the PACE Referral Specialist is responsible for coordinating and processing medical, dental, and optical referrals and authorizations for a variety of settings that PACE participants utilize. This requires the understanding of universal codes such as Current Procedural Terms (CPT), Healthcare Common Procedure Coding System (HCPCS), and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) in addition to International Classification of Diseases (ICD-10). These codes will meet the requirements for specialty services to ensure minimal delay in securing accessibility for participants.

Essential Functions:

• Receives and processes referrals and authorizations in a timely manner.
• Coordinates care with primary care providers and their clinical coordinators in obtaining the necessary documentation needed for outsources care and diagnostics/radiology.
• Interfaces with specialty offices to answer questions regarding referral and authorization statuses.
• Ability to navigate and utilize multiple functions from an electronic medical record platform in producing a comprehensive referral that will satisfy the needs of specialists.
• Oversee the process of obtaining, receiving, and transferring participants' medical records to and from providers outside of PACE, assuring that proper medical release forms are complete and scanning any paper documents into the electronic medical record.
• Conduct medical record audits as assigned.
• Ability to use clinical and administrative judgement under regulations to determine best approach for both urgent and non-urgent patient care needs.
• Maintain HIPAA standards and adhere to policies and procedures that govern the confidentiality of healthcare sensitive information.
• Request additional medical records from specialty offices and clinic for further review by Utilization and Network Manager and/or PACE Medical Director as needed.
• Maintains established departmental policies and procedures, objectives, quality assurance program, safety and environmental.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
• Attends meetings as required and participates in committees as directed.
• Ability to multi-task, be flexible, ensure accuracy, and meet changing priorities in a fast-paced, high-workload environment.
• Ability to work with others as a core centralized team in addition to maintaining good interpersonal interactions with clients as a member of a multi-disciplinary community health team with a diverse multi-cultural population.
• Adheres to Gary and Mary West PACE core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
• Performs other duties as required or requested in a positive and helpful manner to ensure a smooth-running work area.

• Adheres to all GMWP Policies and Procedures, GMWP Safety Policies and Procedures and OSHA safety guidelines.
• Must demonstrate regular attendance and punctuality.
• Brings issues and process improvement ideas to the attention of the Supervisor.
• Maintains verbal and written skills required for the position.
• Completes annual trainings as required.
• Adheres to Company Dress Code Policy.
• Demonstrates appropriate level of time management in support of co-workers and the entire team.

Education and Certification:

• High school diploma or GED equivalent required.
• Medical Terminology Certification preferred.
• Medical Assistant Certificate preferred.

Skills and Experience:

• One year of health care experience working with frail and/or chronically ill elderly population.
• One year experience in a healthcare setting including front and back-office exposure.
• One year experience in referral and authorization processes for managed care insurance platforms.
• Must have excellent written and verbal communication skills and demonstrate the ability to interact clearly and effectively with both internal and external customers.
• Prior exposure working with and electronic medical record platform. Proficient in Microsoft Word and Excel.
• Skilled in establishing and maintaining effective working relationships with participants, co-workers, vendors, medical staff, and the public.

Medical Clearance:

Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.

Job offers are contingent upon a successful pre-employment drug screen, background check, and physical assessment.

Gary and Mary West PACE provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, pregnancy, military and veteran status, age, physical and mental disability, genetic characteristics, gender, gender identity, gender expression or sexual orientation or any other considerations made unlawful by applicable state or local laws.