Referral Coordinator

Title:
Patient Care Coordinator, Referral Management

Job Type: Full-time

Location:
Hybrid — 4 days per week in Brighton, MA office; 1 day remote

FLSA Status:
Exempt

The Patient Care Coordinator, Referral Management supports members' access to specialty and ancillary care by processing referral authorizations accurately and efficiently within a capitated, HMO-model TRICARE Prime / US Family Health Plan (USFHP) framework, keeping care in network wherever appropriate. This non-clinical role is a key point of contact for members and provider offices, coordinating the administrative components of the referral process, verifying eligibility, benefits, and network status, and ensuring a smooth, timely, and service-oriented experience for veterans and military-connected members.

The Patient Care Coordinator works closely with clinical staff, recognizes when a request requires clinical review, and escalates appropriately to help members navigate the system, resolve access barriers, and close the loop on outstanding needs. The role also provides administrative support to the Utilization Management, Case and Care Management, Quality, and Clinical Operations teams as assigned. Success in the role is measured by accuracy, timeliness, compliance, and member and provider satisfaction.

• Receive, review, and process referral and authorization requests for completeness, accuracy, and network appropriateness, including PCP-initiated specialty referrals, out-of-network requests, and ancillary services.
• Ensure referrals are processed within DHA/TRICARE and accreditation turnaround-time requirements and notification standards, in compliance with plan policy.
• Track pending referrals to resolution and follow up proactively on outstanding information.
• Approve referrals that meet established administrative criteria within delegated authority, and route any request that cannot be approved administratively for clinical review; non-clinical staff do not issue medical necessity denials.
• Direct referrals to contracted, in-network providers and sites of care whenever available, and flag out-of-network requests and network gaps for review in support of the plan's capitated care model.
• Generate and send referral authorization notifications to members, requesting providers, and servicing providers, and manage authorization extensions, visit-count changes, and expirations.
• Coordinate with Claims and Provider Relations to resolve authorization-related claim issues and discrepancies.

• Verify member eligibility, benefit coverage, and network/provider status in accordance with TRICARE/USFHP requirements.
• Confirm required documentation and coding is present before processing and request missing information as needed.

• Identify requests requiring clinical or medical necessity review and route them promptly to Utilization Management nurse reviewers with complete supporting documentation.
• Recognize urgent or expedited requests and handle them according to plan protocols.
• Identify members who may benefit from case and care management, such as those with repeat, complex, or multi-specialty referral needs, and refer them to RN Case Managers.
• Identify and refer potential quality-of-care concerns and potential fraud, waste, and abuse per protocol.

• Serve as a courteous, responsive point of contact for members and provider offices regarding referral status and access to care.
• Assist members in connecting with in-network specialists and ancillary services and help resolve access barriers.
• Educate members and providers on referral and authorization requirements and processes.