Referral Management Clerk - Lead

Referral Management Clerk - Lead

Referral Management Clerks are responsible for receiving, reviewing, and validating incoming referrals to ensure completeness of required documentation, including clinical chart notes, diagnostic results, and medical necessity support. Processing referrals in accordance with established clinical guidelines, and applicable policies (e.g., TRICARE, DHA, or organizational standards). Utilizing clinical decision support tools and escalating cases requiring additional clinical review to appropriate clinical personnel. Communicating with referring and receiving providers to obtain missing information, clarify clinical intent, and ensure accurate and timely referral disposition. Coordinating care between primary care managers (PCMs), specialists, and ancillary services to support continuity of care. Entering, tracking, and managing referrals within the designated electronic health record (EHR) or referral management system. Assigning referrals to appropriate direct care or network providers based on clinical need, availability, and contractual requirements. Ensuring referrals are processed within established timeliness standards and performance metrics. Maintaining complete and accurate documentation of all referral activities, communications, and determinations within the system of record. Ensuring compliance with HIPAA, privacy, and security requirements, and adhering to all applicable policies and regulatory standards. Supporting quality assurance activities, including audits, error tracking, and corrective actions. Monitoring performance against key performance indicators (KPIs) and identifying opportunities for process improvement and workflow optimization.

Duties

• Disposition referrals in accordance with current business practices.
• Provide MHS Genesis secure messaging services as required.
• Research, to include but not limited to claims, clinical history, and chart notes.
• Create and update job aids as needed.
• Maintain and track workload distribution to ensure contractual compliance is met.
• Close expired referrals as directed.
• Request chart notes as needed.
• Conduct outbound calls as required.
• Lead quality assurance efforts ensuring adherence to contractual and HIPPA standards.
• Engage in scheduled calibration sessions with leadership to ensure consistency in quality standards and facilitate necessary meetings.
• Host or participate in enhancement sessions (e.g., brown bag meetings) to support continuous improvement.
• Maintain thorough records of deficiencies, improvement opportunities, and positive performance feedback.
• Share trends, identify potential process gaps, and recommend actionable solutions to leadership.
• Develop expertise across departments to support quality initiatives.
• Schedule and lead virtual chairside sessions to guide employees on failed calls, deficiencies, and improvement opportunities.
• Work closely with various departments and organizational leadership to ensure seamless operations.
• Monitor agent adherence to company policies, procedures, and compliance standards.
• Assist with managing help queue calls and ensuring adequate coverage.
• Troubleshoot issues and submit support tickets as needed.
• Document and enter booking infraction for accountability and reporting purposes.

Referral Management Clerk -Lead Job Qualifications:

• High school diploma or General Educational Development (GED) equivalency
• Proficiency in Microsoft 365 including Teams, Excel, and Outlook, with the ability to efficiently navigate and use these tools in a professional work environment.
• Strong computer literacy, including the ability to learn and adapt to new systems, applications, and technologies.
• Demonstrate superior customer service skills, with a professional, courteous, and solutions-oriented approach to internal and external customers.
• Excellent telephone etiquette, including clear, professional, and effective handling of calls and inquiries.
• Strong verbal and written communication skills, with the ability to communicate information clearly, accurately, and professionally.
• Demonstrate critical thinking and problem-solving skills, with the ability to analyze situations, identify solutions, and make sound decisions.
• High level of attention to detail and accuracy in completing work and maintaining records.
• Ability to prioritize tasks, manage multiple assignments, and work effectively in a fast-paced environment.
• Minimum of 1 year Healthcare administrative experience (required).
• Minimum of 1 year call center experience (preferred).
• Minimum of 2 years leadership experience (preferred).
• CXOne, MHS Genesis, and other call center software experience (preferred).
• Must be a US Citizen