Referral Coordinator

Description 

The Referral Coordinator is responsible for verifying patient’s insurance eligibility to determine coverage and benefits for services provided, obtaining prior authorizations/referrals for all procedural orders by successfully completing the authorization process with all commercial payers and provide insurance policy education to patients.   

Knowledge and Skills: 

• Excellent working knowledge of insurance carriers’ payment regulations, copays, coinsurance and deductibles, in-network and out-of -network providers. 

• Knowledge of insurance guidelines; including Medicare, HMO, PPO, & KY Medicaid 

• Experience in health insurance verification preferred 

• High attention to detail and accuracy 

• Experience with medical billing 

• Excellent organizational, problem-solving, time management and interpersonal skills 

•  Clear and concise communication 

• Ability to follow directions and meet deadlines 

• Must be able to work in a fast paced, ever-changing work environment 

• Acts ethically and honestly and applies those behaviors to daily work activities 

• Knowledge of procedure authorization and its direct impact on the practice’s revenue cycle  

• Understanding of payer medical policy guidelines while utilizing these guidelines to manage authorizations effectively 

• Excellent computer skills including Excel, Word, and Internet use  

• Ability to multitask and remain focused while managing a high-volume, time-sensitive workload  

• Basic Medical terminology  

Duties: 

• Ensures the accuracy of patient demographic and insurance information, updating as necessary 

• Collects, verifies and communicates necessary information with member’s insurance carrier to obtain referrals/authorizations, etc. 

• Verifies eligibility and health benefits using various websites 

• Enters insurance information & benefits information in the EHR 

• Adheres to HIPAA privacy and confidentiality regulations and guidelines 

• Training all new employees in insurance verification for Family Care & Specialty Clinics using Availity, Ky Health Net & Passport OneSource, etc. 

• Support for Patient Access as needed (including Sleep Lab Clinic) 

• Insurance Policy & Financial Counseling – (explaining policy on Ortho surgical patients) 

• Coordinate Self Pay Discounts & Qualifications  

• Review chart documentation to ensure patient meets medical policy guidelines 

• Obtain prior authorization via payer website or by phone and follow up regularly on pending cases 

• for pre-cert 

• Prioritize incoming authorization requests according to urgency 

• Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations 

• Collaborate with business office on appeals for denied authorizations  

• Respond to clinic questions regarding payer medical policy guidelines  

• Contact patients to discuss authorization status for pre-certs 

• Provide requested medical records to payers 

• Communicate and educate providers and clinical staff on medical policies 

• Other duties and tasks may be assigned as appropriate or necessary 

Education Requirements: 

• High School diploma or equivalent

• 2 years required insurance verification experience  

• 2 years clinical office setting