Healthcare Insurance and Referral Coordinator

Company: SFP Health Group

Job title: Referral Coordinator – Primary Care

Division/Department: Health Services

Reports to: VP of Health Services/ Director of Value Base Care

Job Summary

The Referral Coordinator plays a crucial role in the healthcare system, ensuring patient referrals are managed and processed effectively. Acting as a liaison between healthcare providers, patients, and insurance companies, the Referral Coordinator ensures referrals are handled in a timely and accurate manner while maintaining compliance with payer requirements. This position is responsible for keeping patients within the network and under the PPN, improving patient satisfaction, and avoiding overutilization of services. The ideal candidate will have a strong understanding of insurance verification, authorization processes, and the ability to navigate all lines of business, including Medicare, Medicaid, Managed Care, Commercial, and Workers’ Compensation.

Essential Duties and Key Responsibilities

Referral Processing & Tracking

Receive, review, process, and track all incoming provider referral requests to specialist providers and diagnostic services.

Schedule patient appointments with specialist providers and confirm receipt of referrals.

Follow up with patients and providers to ensure timely delivery of care.

Maintain updated records of patient referrals, statuses, and outcomes in the EMR and referral tracking systems.

Create and maintain the SFP Health Group Preferred Provider Network list.

Communication & Coordination

Communicate with physicians, nurses, Care Coordinators, and other healthcare staff to obtain necessary patient information.

Coordinate efficiently with the Care Coordinator/Care Management team for any surgical requests.

Review referral details and expectations with patients, ensuring they understand the process.

Contact patients to inform them when authorizations are received and scheduling is confirmed.

Establish and maintain relationships with physicians, MAs, Care Coordinators, and office staff at SFP Health Group.

Insurance Verification & Authorization

Verify patient insurance eligibility, coverage, and benefits for referred services across all lines of business.

Contact insurance companies to ensure prior approval requirements are met.

Obtain required prior authorizations, documenting authorization numbers, effective dates, and service limits.

Maintain up-to-date knowledge of insurance plans, capitations, and educate providers and staff as needed.

Ensure all referral documentation meets payer-specific criteria and is completed accurately and on time.

Patient Support

Answer patient inquiries regarding the referral process in a clear and professional manner.

Provide patients with preparation instructions and expectations for specialist visits.

Ensure all patient communications prioritize satisfaction and timely care delivery.

Documentation & Compliance

Maintain ongoing tracking and documentation of referrals to promote team awareness and patient safety.

Adhere strictly to HIPAA regulations and maintain patient confidentiality.

Ensure compliance with internal protocols, payer guidelines, and regulatory standards.

Identify and resolve issues or delays in the referral process promptly.

Knowledge, Skills, and Abilities

Education & Certifications

High School Diploma or equivalent required.

Certified Medical Assistant (CMA) preferred.

Experience & Technical Skills

Minimum 2 years of experience as a Referral Coordinator or similar role in a primary care setting.

Experience working with multiple payer types and lines of business (Medicare, Medicaid, Managed Care, Commercial, Workers’ Compensation).

Proficient in Excel and Availity.

Knowledge of Athena and other EMR systems.

Knowledge of CPT, ICD-10, and medical terminology.

Interpersonal & Professional Skills

Excellent interpersonal skills with the ability to communicate clearly and effectively with patients and external parties in a courteous and friendly manner.

Must be detail-oriented and highly organized.

Ability to manage multiple priorities in a fast-paced environment.

Knowledge of patient care and examination procedures.

Must be able to maintain confidentiality at all times.

Bilingual skills are a plus.

Physical & Mental Requirements

Ability to stand or sit for extended periods of time.

Ability to receive and comprehend instructions verbally and/or in writing.

Ability to use logical reasoning for simple and complex problem solving.

Occasionally requires exposure to communicable diseases or bodily fluids.

Occasional travel for clinical activities may be required.

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