Referral Coordinator
- Coordination of the Referral Process
- 1) Collects all referrals from medical staff daily and obtains any necessary approvals from attendings.
- 2) Works in all aspects of the referral process, including processing referrals for patients based on primary care physician orders and follow up specialists service recommended.
- 3) Generates necessary correspondence or calls to patients, physicians and office staff, managed care organizations or vendors requesting additional information and requirements for referral authorization.
- 4) Communicates with appropriate Physician, nursing staff and patients regarding follow-up status of referrals.
- 5) Prepare correspondence, input referral information in the automated system, collects additional medical necessity supporting documentation and provide to appropriate parties for approval.
- 6) Attend PHO and other vendor meetings as required to discuss changes in processing requirements.
- 7) Identifies potential problems (i.e., labs, x-rays, procedures, and other physicians) with payment of charges from referral by communication with PHO and other managed care specialists.
- Reviews all payor requirements by type of service and organizes materials to ensure appropriate referral and that steps are followed to avoid claims denials.
- 1) Investigates diagnosis codes and medical necessity guidelines to determine if appropriate based on payor guidelines.
- 2) Discusses any discrepancies with physician for correct coding of referral.
- 3) Provide correct codes both ICD9 and CPT and explains coverage to ordering physician.
- 4) Input codes into automated system and discuss any certification requirements with vendor’s nurse certification specialist.
- 5) Monitors approval status and resubmit request as necessary.
- 6) Identifies need for appeal process with insurance companies and Medicare and initiates process.
- Participate in education and eligibility problem resolution.
- 1) Works with attendings and nurses in the education of physician office staff on referral procedures.
- 2) Acts as a resource to customers and help resolve referrals, claims and eligibility issues.
- 3) Communication with manager, program director, other health care professionals, and various staff in a positive fashion in order to promote patient satisfaction, quality services delivered and resolution of issues.
- 4) Verify eligibility of patients including problem resolution with Advocate MSO and various managed care organizations.
- 5) Identifies and maintains appropriate communication with supervisor involving problems and observations in course of daily operations.
- 6) Other duties as needed.
- Establish controls and a tickler system set-up to see if services are obtained. Maintain tracker to ensure:
- 1) Patient received the services ordered before termination of the referral.
- 2) Patient have proper paperwork before going to the referral site.
- 3) Results are received from the specialist prior to the patient’s next appointment.
- 4) Respond as needed to same day request from patient, if patient urgently needed to see a specialist or forgot paperwork.
- Assures that referral documentation is filed in the medical record and physician sees clinical results of the referrals based on a tracking system put in place.
- 1) Collect all faxed or mailed in consultant reports for referred patients.
- 2) Sort and place in physician mail boxes for review with patient chart.
- 3) Assure that physician has signed off acknowledging review.
- 4) File data in patient chart and re-file the record in the medical records file room.
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