Referrals Specialist-PACE(Temporary)

Referrals Specialist

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

Role Overview and Purpose

The Referrals Specialist will coordinate all referrals and follow-up care for PACE participants. The specialist is also responsible for receiving, processing, scheduling, and following up on all medical referral requests, including in-house and outside referrals for diagnostic testing, medical specialists, or other providers.

This is a full-time temporary position, expected to last about 3 months. Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Responsibilities

Direct Patient Care

• Serves as the main point of contact for providers and clinic staff regarding referrals, authorizations, and appointment scheduling
• Prepares, processes, and completes referrals accurately and in a timely manner, including urgent and stat referrals for assigned PACE location
• Arranges transportation for participants to medical appointments at Neighborhood and other organizations, including escort coordination
• Communicates referral details and appointment information/instructions to participants and their families
• Tracks referrals in the designated logs and/or electronically via electronic medical records (EMR)
• Follows up on submitted authorization requests and maintains consistent status updates via EMR
• Monitors and reports on statuses of authorization requests; escalates issues as necessary until fully resolved and referral loop is closed
• Completes surgery scheduling with proper CPT codes and all needed follow ups, including pre and post order management, labs, EKG, images, etc.
• Manages needs for re-authorization across all clients and payors by working with clinical teams to ensure timeliness re-authorization ahead of expiry to avoid lapses in authorization or delays in patient care
• Reviews consultation reports for needed follow up requests and works with providers to ensure timely processing of all follow ups
• Works with the health information department to ensure timely retrieval of consultation reports
• Reschedules missed appointments and notifies the provider according to no show policies
• Arranges the retrieval of CD images and provides to medical specialist to ensure appointment are kept and completed
• Submits retro-authorizations and distinguishes between primary care and internal specialty visits
• Documents all actions taken in the participant medical record in accordance with current Clinic, DHCS and CMS regulations/guidelines
• Advocates and discusses with participants all aspects of the referral process as needed or requested by the treating provider
• Screens and answers related referral calls by telephone, text message, patient portal, and/or by mail
• Acts as a liaison between participant, clinic/providers, specialty care providers, hospitals, and other community resources

Provider & Team Support

• Obtains referrals and authorizations from providers in timely manner
• Communicates referrals and authorizations information and pertinent medical information to the specialty provider
• Participates in scheduled department meetings
• Shares accountability for overall participant health outcomes, working in coordination with care teams

Customer Relations

• Maintains a professional working relationship with all levels of staff, clients, and the public
• Cooperates, as part of a team, in accomplishing department goals and objectives
• Maintains positive relationships with all participants, prospective participants, clinical staff, prospective employees, fellow co-workers and referral sources

Qualifications

Education/Experience

• High school diploma/GED required
• One year of clinical or healthcare experience required
• Experience with referral authorization and data processing preferred
• One year of experience working with elderly populations preferred
• Bilingual (English/Spanish) highly preferred
• Current Basic Life Support (BLS) certification required upon hire and must be maintained as a condition of employment. These courses must follow AHA guidelines- may be completed through approved online providers such as ProMed or other equivalent programs that meet recognized BLS standards.
• In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually

Additional Qualifications (Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
• Knowledgeable about and experience with current procedural terms (CPT), international classification of diseases (ICD-10), and medical terminology
• Ability to successfully manage multiple tasks simultaneously
• Excellent planning and organizational ability
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 10 lbs/weight
• Ability to stand for long periods of time

Pay range: $22.88-$32.08 per hour, depending on experience.

Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to: the candidate's overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.