Job Description

Referral Coordinator

This position involves analyzing, reviewing, and processing referrals for the authorization of outside medical services. The role requires researching and resolving inquiries from providers, members, and staff regarding specific authorizations. The coordinator will also handle telephone and email communications regarding coverage and eligibility.

Key Responsibilities

• Review, evaluate, and process outside medical service referrals for completeness, accuracy, and timeliness.
• Determine appropriate insurance-based coverages (HMO, Medicare/Medical), service codes, and providers.
• Research referrals from doctors to determine eligibility and obtain required approvals.
• Process claims and understand the revenue cycle and medical billing.
• Provide customer service to referral process stakeholders by responding to inquiries related to authorizations.
• Collaborate with clinical case managers and coordinators to ensure timely authorization processes.
• Ensure outside provider agreements are in place by confirming contract status.
• Code referrals accurately to indicate special claims handling requirements.
• Work within multiple systems to update and edit authorizations.

Required Qualifications

• High School Diploma or General Education Development (GED).
• An Associate's degree or two (2) years of directly related experience in accounting or a related field.
• Previous experience in medical assistance, utilization management/authorization, or coding within a hospital or clinic environment.
• Experience working with health information or medical records/database systems.
• Knowledge of medical terminology, medical coding, or claims processing.
• Proficiency with Excel.
• Must be comfortable with clerical work and lifting/moving paper reems to process physical referrals.
• Customer service, telephone presentation, and problem-solving skills.
• Ability to prioritize work in a high-volume environment.

Preferred Qualifications

• Familiarity with medical procedures.
• Familiarity with Medicare and Medi-Cal benefits.

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