Referral Management Clerk - Lead

• Hourly Pay: $22 - 25.00 per hour
• Health & Welfare Fringe Benefit: $5.09 per hour
• Paid Time Off: 10 days annually (based on 8-hour days)
• Paid Holidays: 11 days per year
• Paid Sick Leave: Accrues at 2.154 hours per 80 hours worked
• 401(k): Company-funded match and Safe Harbor
• Medical, Dental, and Vision Plans Available
• Life Insurance and Accidental Death Coverage
• Short- and Long-Term Disability Plans
• TRICARE Supplemental and Additional Benefit Plans
• Employee Assistance Program
• Pet Insurance Plans
• Will Preparation Services

Referral Management Clerk - Lead Job Overview

• Referral Management Clerks are responsible for receiving, reviewing, and validating incoming referrals to ensure completeness of required documentation, including clinical chart notes, diagnostic results, and medical necessity support.
• Processing referrals in accordance with established clinical guidelines, and applicable policies (e.g., TRICARE, DHA, or organizational standards).
• Utilizing clinical decision support tools and escalating cases requiring additional clinical review to appropriate clinical personnel.
• Communicating with referring and receiving providers to obtain missing information, clarify clinical intent, and ensure accurate and timely referral disposition.
• Coordinating care between primary care managers (PCMs), specialists, and ancillary services to support continuity of care.
• Entering, tracking, and managing referrals within the designated electronic health record (EHR) or referral management system.
• Assigning referrals to appropriate direct care or network providers based on clinical need, availability, and contractual requirements.
• Ensuring referrals are processed within established timeliness standards and performance metrics.
• Maintaining complete and accurate documentation of all referral activities, communications, and determinations within the system of record.
• Ensuring compliance with HIPAA, privacy, and security requirements, and adhering to all applicable policies and regulatory standards.
• Supporting quality assurance activities, including audits, error tracking, and corrective actions.
• Monitoring performance against key performance indicators (KPIs) and identifying opportunities for process improvement and workflow optimization

• Disposition referrals in accordance with current business practices.
• Provide MHS Genesis secure messaging services as required.
• Research, to include but not limited to claims, clinical history, and chart notes.
• Create and update job aids as needed.
• Maintain and track workload distribution to ensure contractual compliance is met.
• Close expired referrals as directed.
• Request chart notes as needed.
• Conduct outbound calls as required.
• Lead quality assurance efforts ensuring adherence to contractual and HIPPA standards.
• Engage in scheduled calibration sessions with leadership to ensure consistency in quality standards and facilitate necessary meetings.
• Host or participate in enhancement sessions (e.g., brown bag meetings) to support continuous improvement.
• Maintain thorough records of deficiencies, improvement opportunities, and positive performance feedback.
• Share trends, identify potential process gaps, and recommend actionable solutions to leadership.
• Develop expertise across departments to support quality initiatives.
• Schedule and lead virtual chairside sessions to guide employees on failed calls, deficiencies, and improvement opportunities.
• Work closely with various departments and organizational leadership to ensure seamless operations.
• Monitor agent adherence to company policies, procedures, and compliance standards.
• Assist with managing help queue calls and ensuring adequate coverage.
• Troubleshoot issues and submit support tickets as needed.
• Document and enter booking infraction for accountability and reporting purposes.

• High school diploma or General Educational Development (GED) equivalency
• Proficiency in Microsoft 365 including Teams, Excel, and Outlook, with the ability to efficiently navigate and use these tools in a professional work environment.
• Strong computer literacy, including the ability to learn and adapt to new systems, applications, and technologies.
• Demonstrate superior customer service skills, with a professional, courteous, and solutions-oriented approach to internal and external customers.
• Excellent telephone etiquette, including clear, professional, and effective handling of calls and inquiries.
• Strong verbal and written communication skills, with the ability to communicate information clearly, accurately, and professionally.
• Demonstrate critical thinking and problem-solving skills, with the ability to analyze situations, identify solutions, and make sound decisions.
• High level of attention to detail and accuracy in completing work and maintaining records.
• Ability to prioritize tasks, manage multiple assignments, and work effectively in a fast-paced environment.
• Minimum of 1 year Healthcare administrative experience (required).
• Minimum of 1 year call center experience (preferred).
• Minimum of 2 years leadership experience (preferred).
• CXOne, MHS Genesis, and other call center software experience (preferred).
• Must be a US Citizen