The Referrals Representative is responsible for processing patient referrals for an assigned site. Responsible for coordinating specialty referrals and diagnostic testing. Pre-certifies diagnostic testing, as required by patient's insurance. Educates the patients on various policies, procedures, and benefits, related to the need for referrals. Assists patients over the phone with scheduling support for medical and gynecological/obstetrics, relaying medical information and/or medical and referral information request. Coordinates referrals with patients and specialist's offices, and process insurance referrals as required. Acts as a liaison between patient, physician and insurance company, consistently performing activities in a friendly, courteous and professional manner.
Every Adelante employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism and competence.
OUR CORE VALUES
- Initiates and manages clinical referrals for pre-authorization
- Acts as a liaison between health plans, physicians, patients and other referral sources
- Obtains authorization on for admissions as required by health plans
- Reviews referrals for completeness and follows up for additional information if necessary
- Process an average of 35 referrals daily
- Responds to inbound calls initiating exam requests following established processes, meets quality and production standards
- Contacts physician offices as needed to obtain demographic information or related data
- Enters referrals, documents communications and actions in system
- Enters patient insurance authorizations and any pertinent information from insurance company into the patient account history
- Manages denials or potential denials as described by insurer
- Monitors and reviews applicable schedule to ensure that authorization and initial length of stay is obtained and on file
- Responsibilities may vary over time. Required to perform other duties as required for the efficiency and effectiveness of the department and job role
- Ensure patient needs and requests are handled efficiently by performing telephonic patient scheduling
- Schedule patient initial and follow up appointments ensuring efficient use of provider time and the appropriate care for patients
- Perform patient pre-registration including accessing and updating patient information as indicated
- Maintain schedule accuracy for maximum patient flow
- Follow established procedures for answering and screening incoming appointment-related telephone calls, scheduling interpreters, and directing calls to appropriate staff
- Maintain effective communication with office staff and providers in all of the health centers as needed
- Attend staff meetings, in-service meetings, or other required meetings
- Maintains good attendance, is punctual and works full scheduled shift
- Demonstrates respectful, professional and appropriate behavior that supports a team oriented work environment
- As needed will be utilized as back-up for the patient support center
Additional Duties and Responsibilities
- Other duties as requested or assigned
All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team based model to promote wellness and improve health outcomes.
Adherence to Compliance and Code of Conduct
All employees are required to comply with Adelante Healthcare’s written standards, including its Compliance Program and Standards of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelante’s legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation.
PHYSICAL DEMANDS AND WORK ENVIRONMENT
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions. The employee must frequently lift and/or move up to 25 pounds without assistance, and may occasionally be required to lift or move up to 50 pounds with assistance. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
Work environment: While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites. The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, blood borne pathogens, etc.) when working in the clinic area.
In any organization or job, changes take place over time. Although an effort will be made to keep job-related information current, this is not an all-inclusive list of job responsibilities. Adelante Healthcare, Inc. reserves the right to revise or change job duties and responsibilities as the business need arises. In compliance with EEOC 29 CFR part 1630, if the essential functions of this position cannot be performed in a satisfactory manner by the employee, further accommodations shall be made if it does not constitute undue hardships upon this organization.
ESSENTIAL SKILLS AND EXPERIENCE
- Exceptional communication skills and professional presence
- Must have great phone etiquette
- Ability to communicate effectively with patients, co-workers, and the general public both in person and over the phone
- High school graduate or GED from an accredited institution
- 1-3 years of experience in a high-volume, interactive customer service or call center environment, with working knowledge of medical terminology or any combination of education and experience, which would provide an equivalent background
- Computerized database experience
- Accuracy and attentional to detail
- Office Suite experience, particularly Excel, Word, and Outlook
- Strong customer service skills
- Strong written communication skills
- Ability to prioritize and perform multiple tasks simultaneously
- Ability to work cooperatively with others in a multi-cultural environment
- Ability to understand and carry out complex oral and written instructions
- Ability to perform a variety of assignments requiring some exercise of independent judgment
- Must possess strong organization and communication skills and be able to work independently and within a team
- Intermediate office skills: typing, faxing, scanning and telephone
- Commitment to Adelante Healthcare’s mission, vision, and values
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job related selection or promotional criteria.