INTRODUCTION:

Central Neighborhood Health Foundation is a Federally Qualified Healthcare Center (FQHC) committed to the Triple Aim as described by the Institute for Healthcare Improvement. Improving the US health care system requires simultaneous pursuit of three aims: 1) improving the experience of care, 2) improving the health of populations, and 3) reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an "integrator") that accepts responsibility for all three aims for that population.

SUMMARY:

The Backlog Referral Coordinator is responsible for managing and processing previously unaddressed or delayed referrals to ensure timely patient access to care. This role focuses specifically on resolving referral backlogs, improving workflow efficiency, and ensuring compliance with organizational and payer requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES include but are not limited to the following functions:

• Responsible for the accurate completion and processing of referral requests from CNHF PCPs as well as from other PCPs to other providers, e.g., specialists, DME, diagnostic testing, etc. Also responsible for the processing of follow-up referral requests from specialists, following the timeliness guidelines in the Policy and Procedure Manual.

• Review, prioritize, and process backlog referrals in a timely and organized manner.

• Ensure that phone calls are answered promptly and courteously and that the correct information is relayed to the caller as appropriate

• Responsible for the upkeep of the current Provider Directory to ensure that the correct contracted providers are being referred to.

• Maintenance of referral logs.

• Responsible for maintaining DHS and NCQA standards and requirements.

• Responsible for notifying patients of the status of their referral in a timely manner; Stat referrals in 2 hours. Urgent in 24 hours, regular in 3-4 days, mammography results in office within 7 days, and Specialist consultation reports within 30 days. To include phone call, mail, or fax as is necessary and/or appropriate.

• Verify patient eligibility, insurance coverage, and authorization requirements.

• File all necessary information in the patient’s charts, e.g., copies of insurance cards, X-Ray reports, lab reports, hospital notes, referrals, consult notes, etc.

• Obtain prior authorizations and ensure all required documentation is complete.

• Coordinate with providers, specialists, and external facilities to schedule appointments.

• Communicate with patients regarding referral status, scheduling, and required next steps.

• Identify and resolve issues causing referral delays or denials.

• Maintain accurate and up-to-date records in the electronic health record (EHR) system.

• Collaborate with clinical and administrative teams to streamline referral workflows.

• Monitor and report progress on backlog reduction and turnaround times.

• Ensure compliance with HIPAA and organizational policies.

• Act as a patient liaison between the UM/QM Departments and the Health Plans to help the patient access care more readily.

• Display a friendly, professional attitude with patients, other staff, and the Physicians.

• Keep patient records confidential.

• Perform other related duties as assigned or requested.
  

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE:

• High school diploma or equivalent required

• 1–3 years of experience in referral coordination, medical administration, or a related healthcare role.

• Ability to handle confidential and sensitive information.

• Ability to communicate effectively on the telephone.

• Ability to relate to people with diverse educational, socioeconomic, and ethnic backgrounds.

• Ability to handle a “call center” environment; work quickly and multitask.

• Ability to exercise good judgment to handle calls appropriately.

• Ability to demonstrate good customer service.

NECESSARY SKILLS:

• Bilingual English and Spanish preferred.

• CPR Certification preferred.

• Experience working with referral backlogs or high-volume case management.

• Familiarity with EHR systems and medical terminology.

• Strong knowledge of insurance verification and prior authorization processes.

• Excellent written and oral communication skills.

• Excellent organizational, time management, and problem-solving skills.

• Ability to work collaboratively with multiple health professionals in a busy and complex environment using tact, diplomacy, and discipline.

• Is a team player who demonstrates a caring and compassionate commitment to the patient and their unique circumstances.

• Computer literate, including word processing, medical office management system applications, and the clinic EHR.

WORK ENVIRONMENT

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 qualified individuals with disabilities to perform the essential functions. Variations in conditions may occur under certain circumstances.

CONFIDENTIALITY

Maintains patient, employee, and Foundation confidentiality at all times, discussing patient or employee business only with appropriate parties who have a bona fide need to know; and communicating only the minimum amount of information necessary with respect to protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

1. AGREEMENT AND ACCEPTANCE

2. I HAVE READ THE ABOVE JOB DESCRIPTION AND FULLY UNDERSTAND THE REQUIREMENTS SET FORTH AND WILL PERFORM ALL DUTIES AND RESPONSIBILITIES TO THE BEST OF MY ABILITY.