Referral/Prior Authorization Coordinator

Job Description

Job Description A Referral Coordinator works collaboratively with physicians, practitioners, counsellors, nurse case managers and other departments to coordinate transfer of care between PCHC providers and community specialists. This person functions as the problem solver for their clinical team – assisting with administrative duties such as completing and expediting referrals, medication prior authorization from different insurance companies, assisting with completion of routine forms, and other logistical duties.

Duties & Responsibilities:

Monitors the electronic health record to receive and process requests for referrals and diagnostic imaging prior authorizations during standard clinical hours. Able to prioritize and successfully process referrals and related forms from multiple providers.

Proactively reviews new referrals and diagnostic imaging prior-authorization requests for completeness and accuracy. Able to interpret standard insurance guidelines to identify incomplete referrals before processing, and communicates directly with the care team regarding any necessary testing or records required for approval.

Has a clear understanding of insurance plans, with knowledge of covered services and community specialists within the insurance company’s network.

Functions as a liaison between insurance companies and care teams for high risk referrals and diagnostic imaging requests. Accesses insurance companies web-based program(s) to check the status of pending prior authorizations. Escalates all unresolved high risk referral issues back to the care team in a timely manner.

Qualifications:

Excellent oral and written communication skills and the ability to effectively communicate medical and behavioral health conditions to community specialists.

Ability to work independently and as part of a health care team.

Basic knowledge/experience in navigating web based portals required, as well as, Microsoft Office products such as Excel, Word, and Outlook.

Attention to detail required.

Medical Terminology required.

Proficiency in use of the PCHC electronic health record and scheduling system, preferred.

Ability to develop positive relationships with community specialists and insurance carriers.

Experience with processing prior authorizations and referrals, preferred.

Knowledge of state and federal health care programs, including Medicaid, Medicare and other public benefits programs, preferred.

Knowledge of HIPAA regulations and ability to maintain strict confidentiality of patient health information at all times.

Experience working with the under-served and uninsured populations.

Access to reliable transportation.

Background check/Life Links access required.

Ability to communicate with people of various diverse backgrounds in a sensitive and compassionate way.

Education:

Minimum of an Associate’s Degree and/or completion of a medical training program.

Prior experience working in an ambulatory care center.

PCHC is EOE/M/F/D/V/SO