Referral Specialist - Brown University Health

Summary:

The Referral Specialist reports to a Program Administrator of the Children�s Neurodevelopment Center. Under the general supervision ensures the quality of the referral and authorization process is upheld to departmental standards. Coordinates the effective and efficient processing and scheduling of all incoming referrals adhering to established timelines and departmental procedures. Ensures the appropriateness and timeliness of practice activities including but not limited to scheduling billing actives including accurate insurance documentation verifications and authorizations.

Responsibilities:

Receives and reviews all incoming referrals ensuring completeness and accuracy. Ensures all information is received including patient demographics insurance and authorizations. Communicates promptly with referring provider and/or patient regarding insurance coverage issues (e.g. non-participation status) so the patient may seek timely services elsewhere.

Evaluates the referral by following established clinic referral guidelines for complete/compliant information.

Determines if referral is in need of additional clarification evaluates the content matter to services requested and determines if the referral needs to be escalated to management for assistance or resolution.

Returns incomplete/non-compliant referrals based on triage guidelines to referring physician office indicating the reason for return.

Documents any communication with referring providers patients and/or Clinic (MD RN etc.) in the EHR.

Provides accurate and timely communication with patients referring providers and other staff.

Schedules appointments according to triage guidelines. Ensures all demographics information is updated insurance verified and authorizations obtained. Notifies patients of appointment explains and educates patient to a level of understanding for the preparation needed for the upcoming appointment. Communicates with referring providers and ensures documentation of that communication in the EHR.

Documents any and all communication with patients in the EHR. Communicates with referring providers when patients decline appointments and/or do not keep their appointments. 

Consistently monitors clinic schedules to ensure maximized scheduling and fills any available/open timeslot including those appointments cancelled and/or rescheduled.

Notifies Provider and/or Manager if unable to schedule referral need to reschedule appointment due to missing referral and/or prior authorization or if there are any other access issues.

Monitors Referral Work-Queues and ensures that all referrals have been processed accordingly.

Confirms patient eligibility with insurance carriers and obtains drug authorizations as necessary.

Ensures effectiveness and accuracy of billing processes for high cost drugs including bulk charges and coding. Maintains data for claims and billing. As directed develops and maintains relationships with external partners including state agencies third party payers and other agencies who conduct business with the department. This includes working with 340B Coordinators to keep up with 340B drug pricing rules and regulations and ensure compliance.

Responds in a timely manner to requests from the billing company(s) and third party payers. Troubleshoots existing and/or potential issues in department business procedures recommends changes as appropriate.

Collaborates with various Brown University Health personnel in order to resolve billing issues prior-authorizations denials and insurance denials/write-offs to prevent high dollar denials

Coordinates all information for managing insurance denials and submit appeal letters as needed.

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Collaborates with physicians and mid-level providers to schedule peer-to-peer discussions to obtain prior authorization of services denied by the patients insurance. 

Develops reports and interprets data to improve patient quality outcomes and office operations. Ensures reports meet the needs of department management. Reconciles claims charges and payments.

Manage department charge work queues.

Active participant in practice-related meetings of relevant clinical departments. Prepares materials for those meetings as requested.

Performs all duties in accordance with Rhode Island Hospital�s mission.

Other information:

BASIC KNOWLEDGE:

Associate degree in health information technology or related field or the equivalent experience in an ambulatory setting. Formal education in medical terminology anatomy and other coding-related course.

EXPERIENCE:

Two years of clinical referral experience required and/or at least one year of related experience in coding/billing and medical record operations in an ambulatory care facility Health Information/Medical Record Department. Familiarity and understanding of the content of the medical record. Spanish speaking strongly preferred. Strong organizational skills with a proven ability to prioritize and handle frequent changes in workload and able to manage competing priorities. Excellent customer service and communication skills with the ability to discuss delicate matters with patients and referring providers required. Demonstrated knowledge and skills necessary to provide care to patients through the life span with consideration of aging processes human development stages and cultural patterns in each step of the care process.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

Work is performed in a typical medical office setting requiring extensive sitting standing and walking. Reads referrals for new patient appointments for the majority of a day. Ability to work under fast paced sometimes stressful conditions to process new patient referrals meeting productivity and accuracy metrics. Organized and able to manage competing priorities ability to use good judgment by showing resourcefulness in problem solving.

Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Brown University Health is a VEVRAA Federal Contractor.

Location: Rhode Island Hospital USA:RI:Providence

Work Type: Per Diem

Shift: Shift 1

Union: Non-Union

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