UM Referral Coordinator

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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.

We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

The role of the Referral Coordinator is to facilitate consistency of information shared across practices to promote care coordination and effective member co-management for behavioral and non-behavioral practitioners. The Referral Coordinator collaborates with clinical team members to evaluate potential over and under utilization of specialty services based on clinical protocols.

ROLE RESPONSIBILITIES

• Prioritizes assigned patient cohorts to ensure specialty referral completion and ensures stat and expedited referrals are completed based on timeliness standards
• Schedules patient (Preferred Providers List of Specialist) and notifies them of appointment information, including, date, time, location, etc.
• Ensures missed specialty appointments are rescheduled and communicated to the physician/clinician.
• Ensures specialist notifications of referral status
• Completes exchange of information by retrieving and ensuring upload of specialty consultation and follow up notes
• Completes documentation based on standardized documentation; to include, but not limited to location, notification of specialist, notification of patient, status of appropriateness reviews
• Enters all Inpatient and Outpatient elective procedures in EMR and contacts specialist for post procedure referral needs
• Follows up on all Home Health and DME orders to ensure patient receives services ordered.
• Completes appropriateness review based on clinical protocols and appropriately refers to Nurse or Medical Director
• Addresses referral-based phone calls for Primary Care Physicians panel and completed phone messages timely
• Facilitates escalation of denied referrals to the clinical team for appeal reviews.
• Adheres to the Policies and Procedures set forth by the Quality Management Committee and performs all additional duties as assigned.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• High School Diploma
• Minimum 2 years of experience in medical management.
• Capacity to interpret health plan benefit decisions

LICENSURES AND CERTIFICATIONS

• Certification as a Medical Assistant preferred

PROFESSIONAL COMPETENCIES

• High level of critical thinking and problem-solving skills
• Strong work ethic and overall positive attitude
• Effective communication skills including verbal and written
• Ability to manage time effectively, understand directions, and work independently in a fast-paced environment