Referral Coordinator

JOB SUMMARY

Under the direct supervision of the PACE Director of Clinical Services, the PACE Referral Coordinator is responsible for receiving, processing, scheduling, and following up on all medical referral requests, including in-house and outside referrals for diagnostic testing, medical specialists, or other providers.

RESPONSIBILITIES

• Serves as the main point of contact for providers and clinic staff regarding referrals, authorizations, and appointment scheduling
• Prepares, processes, and completes referrals accurately and in a timely manner, including urgent and stat referrals for assigned PACE location
• Arranges transportation for participants to medical appointments at High Desert PACE and other organizations, including escort coordination
• Communicates referral details and appointment information / instructions to participants and their families
• Tracks referrals in the designated logs and / or electronically via electronic medical records (EMR)
• Follows up on submitted authorization requests and maintains consistent status updates via EMR
• Request additional medical records from specialty offices and clinic for further review by Director of Clinical Services and / or PACE Medical Director as needed.
• Verify Medi-Cal Eligibility, as needed
• Monitors and reports on statuses of authorization requests; escalates issues as necessary until fully resolved and referral loop is closed.
• Completes surgery scheduling with proper CPT codes and all needed follow ups, including pre and post order management, labs, EKG, images, etc.
• Manages needs for re-authorization across all clients and payors by working with clinical teams to ensure timeliness re-authorization ahead of expiry to avoid lapses in authorization or delays in patient care.
• Reviews consultation reports for needed follow up requests and works with providers to ensure timely processing of all follow ups.
• Works with the health information department to ensure timely retrieval of consultation reports
• Reschedules missed appointments and notifies the provider according to no show policies
• Arranges the retrieval of CD images and provides to medical specialist to ensure appointment are kept and completed
• Interfaces with specialty offices to answer questions in regard to referral and authorization statuses
• Participates in scheduled department meetings
• Shares accountability for overall participant health outcomes, working in coordination with care teams
• Submits retro-authorizations and distinguishes between primary care and internal specialty visits
• Documents all actions taken in the participant medical record in accordance with current Clinic, DHCS and CMS regulations / guidelines
• Advocates and discusses with participants all aspects of the referral process as needed or requested by the treating provider
• Screens and answers related referral calls by telephone, text message, patient portal, and / or by mail
• Acts as a liaison between participant, clinic / providers, specialty care providers, hospitals, and other community resources
• Makes assigned reminder calls
• Performs other duties as assigned

EDUCATION & TRAINING

• Bachelor's degree in social work, healthcare administration, or a related field (preferred).
• Previous experience in healthcare coordination, case management, or similar role.
• Knowledge of Medicare and Medicaid eligibility criteria and healthcare regulations.
• Strong communication and interpersonal skills, with the ability to interact effectively with diverse populations.
• Excellent organizational skills and attention to details
• Proficiency in Microsoft Office Suite and electronic health record systems.

SKILLS & ABILITIES

• Obtains referrals and authorizations from providers in timely manner
• Communicates referrals and authorizations information and pertinent medical information to the specialty provider
• Enters required data, including basic insurance and screening information
• Follows established protocols for patients who indicate they are in crisis
1 day ago