Sr. Referral Specialist

The Sr. Referral Specialist reports to a Patient Access

Manager. Under the general supervision of the

Supervisor(s) of Patient Access, ensures the quality of the

referral process is upheld to departmental scheduling

standards and is responsible for the integrity of the prior

authorization processes for episode -based medication

referrals. Coordinates and ensures patients have received

financial clearance from insurance companies and

troubleshoot as needed.

Evaluates the incoming referral for information that is

accurate and appropriately reflects the patient symptom

to the requested treatment. Ensures quality control of the

referral process is upheld by reviewing the accuracy and

timeliness of referrals through monthly standard reports.

Coordinates the effective and efficient processing and

scheduling of all incoming referrals, adhering to

established timelines and departmental procedures

Responsibilities

Receives and reviews all incoming referrals ensuring

completeness and accuracy. Ensures all information is

received including patient demographics, insurance

eligibility and authorizations. Communicates promptly

with referring provider and / or patient regarding insurance

coverage issues (e.g. non-participation status) so the

patient may seek timely resolutions.

Confirms patient eligibility with insurance carriers / third

party payors and obtains pre-authorization requirements

in accordance with established medical policies.

Coordinates and ensures appropriate insurance

authorizations are obtained and / or received in a timely

manner. Coordinates and ensures appropriate insurance

authorizations are obtained and / or received in a timely

manner.

Collaborates with various Brown University Health

personnel to resolve billing issues, authorization denials

and insurance denials / write-offs.

Evaluates and determines triage when reviewing the

referral by following established clinic referral guidelines

for complete / compliant information.

Determines if referral is in need of additional clarification,

evaluates the content matter to services requested and

determines if the referral needs to be escalated to

management for assistance or resolution.

Returns incomplete / non-compliant referrals based on

triage guidelines to referring physician office indicating

the reason for return.

Ensures quality control of the referral process is upheld

by reviewing the accuracy and timeliness of referrals

through Monthly standard reports.

EDUCATION :

High school degree or the equivalent experience

EXPERIENCE :

Two years of clinical referral and medication prior

authorization experience required with at least one year

of related / or at least one year of related experience in

coding / billing and medical record operations in an

ambulatory care facility Health Information / Medical

Record Department. Demonstrated understanding of the

basic functions of a therapy / treatment plan and

insurance portals needed to successfully obtain prior

authorizations needed for patient care. Familiarity and

understanding of the content of the medical record.

Spanish speaking strongly preferred. Strong

organizational skills with a proven ability to prioritize and

handle frequent changes in workload and able to manage

competing priorities. Excellent customer service and

communication skills with the ability to discuss delicate

matters with patients and referring providers required.

Demonstrated knowledge and skills necessary to provide

care to patients through the life span with consideration

of aging processes, human development stages and

cultural patterns in each step of the care process.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS :

Work is performed in a typical medical office setting

requiring extensive sitting, standing and walking. Reads

orders for new patient appointments and medications for

the majority of a day. Ability to work under fast paced

sometimes stressful conditions to process new patient

referrals and medication prior authorizations meeting

productivity and accuracy metrics. Organized and able to

manage competing priorities ability to use good

judgment by showing resourcefulness in problem solving.

Pay Range : $20.55-$33.93

EEO Statement :

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location :

The Miriam Hospital - 164 Summit Ave Providence, Rhode Island 02906

Work Type :

Mon thru Fri 8a-4 / 430p

Work Shift : Day

Daily Hours : 8 hours

Driving Required : No