Referral Coordinator (Templeton, CA)

Big Future Music Group; Templeton (CA); Hybrid; USD 33,000 - 40,000; Full time

Job summary

Heritage provider network seeks a Referral Coordinator to verify and interpret member health benefits and coordinate with clinics, providers, and DME vendors. You will ensure timely communication and accurate data entry, maintaining collaboration across departments.

Responsibilities include processing referrals, authorizations, and maintaining compliance with CMS timelines, HIPAA, and internal policies. Prior authorizations and strong organization are essential.

Qualifications

• High School diploma or GED is required.
• Minimum 1 year of experience in a medical office with prior authorizations.
• Knowledge of HCPC, CPT and ICD-10 is required.
• Proficient written and verbal communication skills.

Responsibilities

• Verify eligibility and interpret benefits using health plan and CMS websites.
• Prepare referrals and authorizations and refer to appropriate providers/facilities and DME suppliers.
• Coordinate with physician offices, processing staff and other departments to ensure smooth referral workflow.

Skills

Medical terminology

HIPAA compliance

Documentation

Education

High School diploma or GED

Job description

Under the direction of the Clinic Supervisor, this position is responsible to for verifying and interpreting member benefits for the health plans. The Referral Coordinator will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.

1.1

1.1 To be efficient in use of UM prior authorization systems utilized.

1.2 Verify eligibility and benefit interpretation, via health plan and Medicare (CMS) websites.

1.3 Be a resource for providers in regard to questions regarding network specialists.

1.4 Ability to prepare authorizations and refer to appropriate providers/facilities and durable medical equipment (DME) companies.

1.5 Guide and communicate with physician office, processing staff and other departments as needed to ensure collaboration and open discussion regarding all aspects of the referral process. Including responding to messages within the next business day.

1.6 Review accuracy of pending referrals for ICD-10, CPT, HCPC code and provider selections made by the Authorization Clerk staff.

1.7 Ensure referral data entry was accurately inputted into UM systems based on the referral and clinical information submitted.

1.8 Have a complete understanding of established policy and procedure within Heritage provider network regarding the authorization processes.

1.9 Maintaining assigned duties in an acceptable manner.

1.10 Inform management on a daily basis when problems arise or when work falls behind.

1.11Compile and document good faith attempts in obtaining medical records for each pending referral when there is lack of information.

1.12 Compile clinical based guidelines, criteria and/or benefit information prior to forwarding referral to UM Managers for clinical review.

1.13 Maintain filing in a timely manner.

1.14 Provide Referral Coordinator coverage as needed.

1.15 Process referral published on daily trending reports to maintain compliance with health plans and CMS timeframe regulations.

1.16 Follow and have a complete understanding of the health plan and CMS regulations regarding timelines standards, benefit, and guideline hierarchy.

1.17 Adaptable to regulation and necessary departmental procedure changes that affect UM prior authorization processes.

1.18 Compliance with HIPM regulations and maintain patient confidentiality.

1.19 Cultural and Linguistics training required annually.

1.20 Other duties as assigned.

Requirements

8.1 High School graduate or GED certification required.

8.2 One-year minimum experience working in a medical office environment (IPA or HMO preferred) with prior authorizations required.

8.3 Knowledge of medical terminology required.

8.4 Knowledge of HCPC, CPT and ICD-10, required.

8.5 Proficient written and oral communication skills.

8.6 Demonstrate proficiency in computer systems utilized.

8.7 Ability to remain organized and able to manage competing priorities.

8.8 Demonstrate good judgement.

8.9 Demonstrate ability to take and follow through with delegated tasks and accountability.

8.10Demonstrate resourcefulness in problem-solving.

The pay range for this position at commencement of employment is expected to be reasonably between $24.27 and $28.55. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience. If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

undefined

Employer Privacy Policy

EEO is the Law

ADP Privacy Statement Artificial Intelligence Google Privacy Policy Google Terms of Service