Referral & Eligibility Supervisor JobDallas, TX
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Why You'll Love This Job
General description:
The Referrals Supervisor provides direct oversight to the Referral Coordination Team. This team is responsible for new patient scheduling, managing all internal and external referrals, and medication prior authorizations. The Referrals Supervisor ensures team effectiveness in gathering intake and insurance information, verifying provider network participation, scheduling new patients, and closing the loop on incoming and outgoing referrals.
The Referrals Supervisor also understands all forms of financial resources available to patients for the services they receive at PHNTX. This includes both third-party coverage and other resources such as (but not limited to) Ryan White program eligibility, other grant coverage, payment plans, and income-based sliding fee scale. The Referrals Supervisor and their team assist new patients in determining eligibility for and accessing related services.
The Referrals Supervisor provides direct oversight to the Referral Coordination Team. This team is responsible for new patient scheduling, managing all internal and external referrals, and medication prior authorizations. The Referrals Supervisor ensures team effectiveness in gathering intake and insurance information, verifying provider network participation, scheduling new patients, and closing the loop on incoming and outgoing referrals.
The Referrals Supervisor also understands all forms of financial resources available to patients for the services they receive at PHNTX. This includes both third-party coverage and other resources such as (but not limited to) Ryan White program eligibility, other grant coverage, payment plans, and income-based sliding fee scale. The Referrals Supervisor and their team assist new patients in determining eligibility for and accessing related services.
Responsibilities
Specific Responsibilities of the Job:
Direct Reports:
- Ensures each new or returning patient is met with personally and welcomed to (or back to) care at PHNTX. Ensures team collects relevant financial, insurance, demographic, and basic clinical data and documents. Ensures data is accurate, complete, and timely; documents and updates in the EMR and/or other systems as assigned.
- Researches and explains to new patients with third-party coverage the details of their coverage, including such details as effective dates, in/out of network status, PCP referral requirements, deductibles, co-pay/coinsurance amounts, etc. Obtains authorizations, pre-certifications, etc., as required. Presents estimated patient out-of-pocket costs, non-coverage notifications, and payment options.
- For new patients without third-party coverage, assesses eligibility for existing assistance programs. Explains eligibility criteria, documentation requirements, estimated patient out-of-pocket costs, and payment options. Assists patients in enrolling in qualified program(s), collects and maintains required documentation.
- Demonstrates a thorough understanding of all types of third-party coverage such as Medicare, Medicaid, commercial plans, and both FFS and Managed Care options. Demonstrates ability to accurately determine, calculate, communicate, and document benefits and estimated out-of-pocket costs for specific care to be delivered.
- Demonstrates a thorough understanding of all eligibility programs available at PHNTX such as income-based fee scales, Ryan White program, other grant programs, prompt-pay adjustments, and payment plans. Demonstrates ability to accurately determine, calculate, communicate, and document eligibility and out-of-pocket costs for specific care to be delivered. Understands and follows eligibility determination/re-determination and other program requirements.
- Demonstrates a thorough understanding of internal, external, incoming, and outgoing referral processes, including communications and documentation. Provides leadership and direct supervision to PHNTX’s Referral Coordination Team members, including performance management, training, and daily support.
- Manages referral workflows, ensuring closed-loop communication for all internal and external referrals across medical, dental, and behavioral health services. Reviews referral and scheduling metrics regularly to ensure timely and patient-centered service delivery.
- Maintains a workload of both scheduled and unscheduled patient/co-worker/provider calls, questions, and in-person appointments. Workload involves staff supervision and new patients at all PHNTX locations. Work is performed on site.
- Schedules medical and other patient appointments upon resolving pending coverage/eligibility questions. Oversees the process for all new patient scheduling, ensuring accurate collection of intake and insurance data, and scheduling with in-network providers.
- Collaborates with clinical leadership and support staff to address barriers or delays in referral or scheduling workflows.
- Participates in quality improvement and process optimization initiatives related to scheduling, prior authorization, and referrals.
- Ensures accurate and timely completion of all medication prior authorizations in collaboration with clinical providers.
- Demonstrates understanding and performance of relevant functions in the EMR and other clinic systems and processes. Ensures compliance with applicable PHNTX policies, payer requirements, and regulatory guidelines related to referral and authorization processes.
- Communicates kindly and professionally with patients, families, and caregivers. Cooperates and collaborates with other PHNTX personnel to deliver an exceptional patient experience. Corresponds with payors, referring providers, patients, clinical staff, and others as needed to accomplish job responsibilities.
- Remains current and expert in field. Maintains required certifications. Participates in training and professional development as assigned.
- Other duties as assigned.
Direct Reports:
- Referral Coordinators
Skills & Qualifications
Required Knowledge, Skills and Abilities:
Education and Experience:
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- Ability to effectively use Microsoft Office (Word, Excel, PowerPoint, Outlook) required.
- Strong skills using and navigating athenaOne and/or other electronic medical/health records (EMR/EHR)s required.
- Familiarity with basic medical terminology required.
- Knowledge of third-party payors and eligibility programs at level of proficiency to effectively perform the job responsibilities. Ability to effectively navigate payors’ and eligibility programs’ call centers, portals, documentation, and other information sources.
- Ability to communicate professionally and effectively with patients, families, and agency staff at all levels.
- English/Spanish bilingual preferred.
Education and Experience:
- Bachelor’s degree preferred.
- Associate’s degree (if no Bachelor’s) and/or relevant certification (such as CPhT, CPC/CMC, RHIA/RHIT, CHW, Certified Medical Assistant, CNA, LVN/LPN, RN) required.
- Certified Pharmacy Tech and/or other pharmacy experience/expertise desirable.
- At least 3 years of full-time paid work experience in a healthcare environment required.
- Understanding of ICD-10, CPT codes, physician billing, third party reimbursement required.
- Previous work experience with insurance verification, prior authorizations, and/or claims processing required. Previous work experience determining eligibility for government, program, public or patient assistance funding required.
- The successful candidate will demonstrate critical thinking, problem-solving, attendance/reliability, and communication skills. The successful candidate will demonstrate a high level of rigor and accuracy, flexibility, eagerness to learn, accountability, and will work collaboratively and effectively as part of a multidisciplinary team.