Referrals Specialist

General Summary: The Referral Specialist focuses on the internal GMG referral processes, obtaining authorization from health plans and other UM entities for referrals, obtains LCD/NCD (Local and National Coverage Determination) from Medical Coverage Database and communicating the outcome to patients, specialists, and other providers. This role seeks to enhance appropriate utilization by using GMG services and preferred providers for medically necessary care.


Supervisory Responsibilities: This position has no supervisory responsibilities.

General Requirements: All duties performed will be done accurately and in a timely manner.

1. Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
2. Ensures customer service is always maintained at the highest level.
3. Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
4. Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
5. Participates in educational programs as needed.
6. Bilingual English/ Spanish fluency preferred.
7. Other duties as assigned.
8. Maintains strictest member and company confidentiality.

Essential Job Responsibilities:

1. Run daily referral reports to create work list and monitor referrals in process.
2. Research chart for supporting documents and process referrals according to departmental goals, and accepted protocol, including referrals from internal GMG system, fax and mail from health plans, specialists, and other providers.
3. Verify insurance eligibility and benefits from HMO eligibility lists or by contacting insurance companies by phone when needed.
4. Ability to review a high volume of referral cases with CMO telephonically, enter referral information in the computer system using correct coding procedures (LCD/NCD (Local and National Coverage Determination); Document sufficient referral detail so it is clear what was requested, what occurred, what was approved, and who was notified.
5. Notify patients of the referral process, authorization decisions, and verify their understanding.
6. Notify referral provider of authorizations in a timely manner.
7. Conducts periodic review of previously authorized ongoing care for continued need and or eligibility.
8. Notify supervisor of problem referrals where turnaround goals are exceeded, or other issues are encountered.
9. Acts as liaison for Managed Care and PCP when patient has questions.
10. Serves as clinic information source regarding managed care and referrals.

Work Environment: Depending upon the area assigned, may be 100% clinical setting, office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.


Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 10 lbs. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.


Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.


Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.

Education and Training: Minimum high school education or equivalent. Medical Assistant Certificate preferred.


Experience: Previous experience in managed care referrals. Must have knowledge of ICD-10 and CPT-4 coding, and medical terminology.


Other Requirements: Computer Skills : Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.