TuftsMedicine Referral Navigator I - Remore/Hybrid

Tufts Medicine is a leading integrated health system bringing together the best of academic and community health care to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, Melrose/Wakefield Healthcare, an expansive home care network and a large clinically integrated physician network, Tufts Medicine has more than 15,000 dedicated employees and caregivers.

Job Overview

Reporting directly to the Halmark Health PHO (HHPHO) Central Services Manager. This role is responsible for "navigating" patients through our healthcare system by scheduling appointments with specialists at the point of contact to provide expedited and convenient service.Responsible for handling all inbound calls, requests and processing all insurance referrals for Hallmark Health PHO (HHPHO) & Lowell General Hospital PHO (LGPHO) Primary Care Providers (PCPs). Communicates regularly with Primary Care Provider (PCP) and Specialty Provider offices and maintaining relationships with Emergency Departments and affiliated Urgent Care Centers.Responsible for handling all inbound calls and requests for the Provider Finder Line program and following up with patients in need of primary or specialty care.Responsible for following the HHPHO/LGPHO referral guidelines and working with the PCPs, PHO Medical Directors, office staff, and the patient to help direct care, when medically appropriate, to a specialist within the TuftsMedicine network and to TuftsMedicine services. Supports our PCP offices by making outreach calls to help improve the Quality Measures/Scores of our patients to ensure they are getting the appropriate care they need.

What We Offer

Competitive salaries & benefits that start on day one

403(b) retirement with company match

Tuition reimbursement

Free on-campus parking

Career growth opportunities

Guaranteed hours and set schedule

Location: Remote with an occasional onsite presence at Woburn/Stoneham locations.

Hours: Full-Time, 40 Hours. Day Shift: 8:30am-5:00pm, Monday-Friday.

Job Description

Minimum Qualifications:

1. High School graduate or equivalent

2.One (1) year of health care experience in patient registration or physician office.

Preferred Qualifications:

1. Three (3) years of health care experience in patient registration or physician office.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Responsible for maintaining relationships with Emergency Departments and affiliated Urgent Care Centers to ensure patients in need of a primary care provider or follow up specialty care are addressed.

2. Responsible for handling all inbound calls and requests for the Provider Finder Line program and following up with patients in need of primary or specialty care.

3. Responsible for following the HHPHO/LGPHO referral guidelines and working with the PCPs, PHO Medical Directors, office staff and the patient to help direct care, when medically appropriate, to a specialist within the TuftsMedicine network and to TuftsMedicine services.

4. Supports our PCP offices by making outreach calls to help improve the Quality Measures/Scores of our patients to ensure they are getting the appropriate care they need.

5. Utilizes effective customer service etiquette and skills in all phases of telephone and email communication.

6. Responds immediately to patients or Primary Care Physician (PCP) requesting specialist appointments and works with offices to schedule at the point of initial contact to keep care well-coordinated within the TuftsMedicine referral circle.

7. Tracks number of appointments made and responsiveness and appointment availability by Specialty practice. Alerts Manager regarding appointment access issues or problems. Works to achieve/exceed performance goals set by the PHO (such as answer rates, average customer hold times, and number of contacts handled, etc.)

8. Maintains excellent rapport and ongoing communication with the physician office staff, providers and co-workers.

9. Maintains a basic knowledge of insurance referrals, eligibility, prior-authorizations, broad scope of benefits, subscriber vs. guarantor, and order of insurance.

10. Confirms eligibility of the member being referred/scheduled.

11. Processes referral requests via insurance websites as well as other systems that may be needed to submit an electronic referral and accurately enter them into the patient's Electronic Medical Record (Epic) and communicates this information to specialty offices.

12. Process paper referrals for those insurance plans that do not have electronic capabilities.

13. Schedules appointments and processes referral requests via live telephone calls, fax, Epic workqueues, Epic In-Basket Messages and voicemail messages.

14. Communicate with patients the reason for the re-direct in care and coordinate appointments with an in-circle specialist or service.

15. Communicates with PCPs to discuss possible redirection of out of circle referrals.

16. Communicates with the Medical Director to review any referral request that was approved by the PCP for their patient to see an out of circle specialist and reports back to Manager with results.

17. Follows established HHPHO/LGPHO guidelines regarding all out of circle referrals; including pending referrals for review by PCP or Medical Director and educating the patient regarding referral policies and protocols.

18. Assists PCPs in processing out-of-state referrals based on the various insurance guidelines.

19. Utilizes TigerConnect to reach out to patients and communicates with other providers.

20. Delivers offices marketing materials when needed.

21. Occasionally attend Meetings as needed to give status updates on call volume, office training feedback or other relevant topics.

22. Assists with the daily operations of the Managed Care Department and the PHO as needed, including help with mailings.

23. Maintain a level of professional knowledge commensurate with industry requirements in regard to the rules of the ever-changing insurance referral standards.