Referral Coordinator 26-00306

The Care Management Coordinator supports members by facilitating care coordination, managing referrals, and helping ensure access to appropriate healthcare services. Working under the direction of the Care Management team, this role assists with coordinating services, obtaining medical documentation, addressing access-to-care issues, and supporting care managers in the delivery of timely and effective member care.

The ideal candidate has customer service experience in a medical clinic, hospital, or Independent Practice Association (IPA), along with strong communication, organizational, and data-entry skills. Experience in managed care and utilization management is preferred.

Key Responsibilities

• Assist members with care coordination and referrals for durable medical equipment (DME), home health services, specialist appointments, and other healthcare needs.

• Contact healthcare providers by phone, fax, or email to obtain medical records and additional documentation required for referrals.

• Support Care Managers in coordinating services and managing the care of members with identified care management needs.

• Help facilitate continuity of care by coordinating Letters of Agreement (LOAs) when appropriate.

• Collaborate with Care Managers, nurses, supervisors, and other team members to address member care concerns and support timely implementation of treatment plans.

• Coordinate member disenrollment, transportation, language interpretation, and other services as needed.

• Assist with monthly Health Risk Assessment (HRA) outreach and follow-up activities, including support for Complex Case Management.

• Identify gaps in Healthcare Effectiveness Data and Information Set (HEDIS) measures and contact members to help address outstanding care needs.

• Assist members experiencing access-to-care issues involving primary care providers, specialists, radiology, physical therapy, occupational therapy, speech therapy, and other ancillary services.

• Monitor telephone queues and respond to member inquiries in a courteous and professional manner.

• Maintain accurate documentation in accordance with applicable regulatory requirements and accreditation standards.

• Consult with assigned nurses before taking action involving clinical assessments or decisions.

• Protect confidential member information and comply with HIPAA requirements and organizational policies.

• Participate in team meetings and contribute to a collaborative, quality-focused work environment.

• Perform additional duties as needed to support Care Management operations.

• At least two years of customer service experience in a medical clinic, hospital, or IPA required.

• Experience in a managed care environment preferred.

• High school diploma or GED required.

• Associate's or bachelor's degree from an accredited institution preferred.

• Medical Assistant certification preferred.

• Knowledge of healthcare referrals, utilization management, and care coordination processes.

• Familiarity with HMO or managed care environments, Medi-Cal, and Medicare managed care preferred.

• Familiarity with ICD-10 and CPT codes preferred.

• Strong written and verbal communication skills, including professional telephone etiquette.

• Excellent organizational, interpersonal, and customer service skills.

• Data-entry experience and proficiency with Windows-based applications.

• Typing speed of approximately 45 words per minute.

• Ability to handle frequent telephone interactions, manage multiple tasks, and maintain accurate records.

• Patience, attention to detail, and the ability to work effectively in a team-oriented environment.

• Cultural awareness and sensitivity when working with a diverse member population.