Referral Specialist

Referral Specialist

The Referral Specialist supports continuity and coordination of care by acting as a liaison between patients, providers, internal departments, specialty services, and payers for services not completed during the concurrent patient visit. This role is responsible for initiating, tracking, and closing the loop on all departmental referrals within established timelines, obtaining and managing prior authorizations for medications, diagnostic testing, and procedures, and ensuring clear, timely communication and documentation across the care team and with patients. The Referral Specialist works closely with providers, nursing, clinical support staff, specialty offices, and health plans to ensure referrals are completed accurately, efficiently, and in compliance with organizational policies and payer requirements. Performs other duties as assigned or required.

Referral Coordination and Loop Closure

• Initiate, track, and ensure loop closure of all internal and external departmental referrals within defined timelines, in accordance with referral follow-up procedures.
• Monitor open, pending, incomplete, or overdue referrals in the referral/order tracking system to ensure continuity of care and timely patient follow-up.
• Maintain an accurate referral tracking database and referral logs, ensuring receipt of specialist reports, test results, and consult notes.
• Proactively follow up with specialty offices, diagnostic centers, and internal departments to obtain missing documentation or results needed to close referrals.
• Escalate delays, barriers, or breakdowns in referral completion to providers and leadership as appropriate.

Prior Authorizations and Appeals

• Obtain prior authorizations from health plans for medications, procedures, imaging, and diagnostic testing by submitting required clinical documentation via electronic portals, fax, or telephone.
• Track authorization status and ensure approvals, denials, and requests for additional information are addressed promptly.
• Coordinate with providers to supply clinical justification and supporting documentation for prior authorization requests.
• Initiate and track appeals for denied prior authorizations, including resubmission of documentation and coordination with providers as needed.
• Communicate payor determinations clearly and timely to providers, care teams, and patients.

Communication and Care Coordination

• Communicate with patients and referral sources via telephone, mail, electronic messaging, and other approved methods to notify them of referral status, scheduled appointments, authorization outcomes, and next stepswell in advance of appointment dates when possible.
• Communicate with specialty offices to obtain all pertinent referral information, scheduling details, and clinical requirements.
• Serve as a point of contact for internal and external staff to resolve pending, denied, or otherwise problematic referrals and authorizations.
• Communicate promptly with providers regarding referral issues, authorization challenges, payer determinations, or patient decisions that may affect care plans.
• Ensure clear, consistent, and thorough communication across the care team from front desk to clinical staff to providers and with patients, supporting patient understanding and engagement in their care.

Documentation and Compliance

• Ensure all referral, authorization, and appeal activities are accurately, timely, and thoroughly documented in the electronic health record and applicable tracking systems.
• Manage incoming and outgoing fax communications related to referrals, authorizations, clinical documentation, and specialist reports, ensuring documents are properly indexed, routed, and retained according to policy.
• Adhere to organizational policies, payer requirements, and regulatory standards related to referrals, authorizations, patient privacy, and documentation.
• Assure quality of care by following evidence-based care guidelines, supporting continuity of care, and complying with state, federal, and other governing agency regulations.

Professional Responsibilities

• Participate in FHC employee engagement activities, organizational initiatives, and community events as requested.
• Maintain professional and technical knowledge by attending educational workshops, staff meetings, trainings, and clinical committees as required.
• Perform other duties as assigned to support clinic operations, patient access, and continuity of care.

Typical Working Conditions

• While performing the duties of this Job, the employee is regularly exposed to airborne particles or may be exposed to blood borne pathogens
• The noise level in the work environment is usually quiet

Typical Physical Demands

• While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel and talk or listen
• The employee is frequently required to stand and walk
• The employee is occasionally required to sit; reach with hands and arms and stoop and kneel
• The employee must occasionally lift and/or move up to 25 pounds
• Specific vision abilities required by this job include close vision, color vision and ability to adjust focus

Qualifications

• Insurance coding and medical terminology
• Medical Office Experience
• Familiarity with insurance programs, preauthorization and/or referrals
• Effectively uses Healthcare information systems, such as electronic health record and practice management systems experience
• Multi-line phone proficiency
• Knowledge of medical terminology
• Experience in customer service, organizational skills, clinical processes, programs and strong computer skills are highly preferred

Education/Experience/Certifications/Licenses

• High School Diploma or GED, required
• Medical Assistant or Certified Nursing Assistant preferred
• Associate's Degree from an accredited college or university is preferred
• Experience in a healthcare setting or an equivalent combination of education and experience in a healthcare setting, 1-2 years preferred
• Bilingual (English and Spanish) highly desired