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Referral Reviewer 

Take the next step in your healthcare career as a Referral Reviewer. This role is ideal for experienced nurses who excel in clinical review, referral management, and insurance verification within a fast-paced environment. Become part of a team dedicated to delivering exceptional home health services through accurate assessments and efficient care coordination.

Job Description

The Referral Reviewer is responsible for reviewing and processing incoming patient referrals to determine eligibility and appropriateness for home health services. This role works closely with referral sources, case managers, social workers, intake teams, clinical staff, and insurance providers to ensure accurate and timely referral review, insurance verification, and clinical assessment. The Referral Reviewer plays a key role in supporting efficient admissions processes and ensuring patients can be safely and effectively cared for in the home setting. 

Responsibilities

Referral Management 

  • Review incoming patient referrals received through referral management platforms such as CarePort, Allscripts, and other electronic referral systems. 
  • Process a high volume of referrals while maintaining accuracy and compliance with agency standards. 
  • Assess referral documentation for completeness and identify missing information as needed. 
  • Enter and maintain referral information in agency systems. 

Clinical Review 

  • Conduct preliminary clinical reviews of referral documentation. 
  • Evaluate patient diagnoses, medical conditions, and care needs to determine appropriateness for home health services. 
  • Collaborate with clinical leadership and interdisciplinary teams regarding patient eligibility and acceptance decisions. 
  • Determine whether patient care needs can be safely managed within the home environment. 

Insurance Verification 

  • Verify insurance coverage, benefits, authorizations, and payer requirements. 
  • Identify potential reimbursement issues and communicate findings to appropriate stakeholders. 
  • Ensure all insurance-related documentation is obtained prior to admission whenever possible. 

 Communication and Coordination 

  • Communicate with case managers, discharge planners, social workers, physicians, and other referral sources to obtain or clarify patient information. 
  • Follow up on incomplete referrals and gather additional clinical and insurance documentation as necessary. 
  • Serve as a liaison between referring facilities and agency clinical teams. 
  • Provide timely updates regarding referral status and admission decisions. 

Admission Support 

  • Coordinate with intake and admissions teams to facilitate timely patient onboarding. 
  • Assist in ensuring referral reviews are completed promptly to support agency admission goals and response time standards. 
  • Monitor referral pipelines and prioritize urgent cases appropriately. 
  • Compliance and Documentation 
  • Maintain accurate referral records and documentation in accordance with agency policies, payer requirements, and regulatory standards. 
  • Protect patient confidentiality and comply with HIPAA regulations. 
  • Adhere to all federal, state, and accreditation requirements related to referral and admission processes. 

Minimum Qualifications

 

  • U.S Registered Nurse in New York  
  • Experience in home health, healthcare intake, referral management, case management, utilization review, or insurance verification preferred. 
  • Experience using referral platforms such as CarePort, Allscripts, or similar systems preferred. 
  • Knowledge of  managed care, and commercial insurance requirements.
  • Strong clinical review and critical-thinking skills. 
  • Ability to analyze referral information and make sound recommendations. 
  • Excellent communication and relationship-building skills. 
  • Strong organizational and time-management abilities. 
  • Proficiency in electronic medical records (EMR) and referral management systems. 
  • Ability to manage a high-volume workload in a fast-paced environment. 
  • Attention to detail and accuracy in documentation.
Date Posted:

29 minutes ago

Location:

SJDM, Bulacan

Title:

Referral Reviewer 

Job Type:

Full-time

Category:

Non-Clinical

Account:

Voice and non-voice accounts

Shift:

Night Shift

Experience Level:

Experience in home health, healthcare intake, referral management, case management, utilization review, or insurance verification preferred. 

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