JOB PURPOSE: The role is to supervise the referral process to all outpatient services for the health plan. They provide clinical oversight, triage, and risk stratification for the referral process. They possess a working knowledge of the CenterLight network and collaborate with the medical providers on medical necessity decisions. In addition, the role collaborates closely with the CenterLight medical and operational leadership on creating processes and systems to robustly manage outpatient referrals in a way that enhances high-quality, timely, efficient, effective, and patient-centered outpatient utilization. Referrals Management also involves interacting with the participants and network providers, making referrals to medical practices and/or navigating the participant through the system and creating real-time alternatives to meet their needs in a timely and efficient way. JOB RESPONSIBILITIES: + Overseeing the entire referral process and responding to participant issues with an action plan. + Gathering clinical information, providing thorough review, and ensuring the relevant information is present for decisions on medical necessity. + Providing clinical triage to participants based on the nature of their needs and evidence-based protocols. Prioritizing Urgent referrals and following the entire process through to confirm scheduled appointments. + Processing referrals as deem appropriate and based on the presence of all the necessary elements and escalating referrals to providers as deem necessary + Ensuring timely responses to all participant requests and other providers of care as directed by the liaison providers. + Assisting the participants in navigating the system, explaining the PACE benefits and helping them match their needs with the appropriate service. + Tracking and reporting referrals and action plans including appointment scheduling. + Follow-up on untimely responses or if other problems occur. Responds with an action plan to address issues. + Collaborates with health care providers at inside and outside entities ensuring that the system of processing referrals is working and minimizing risk to patients and providers. + Maintains up-to-date working knowledge of CenterLight providers network and routines and requirement of health care providers with whom referrals are coordinated. + Communicates updates and changes related to the referral process or provider requirements to the CMO, and other members of the interdisciplinary care team as appropriate. + Continuously improving the process design and effectuation is meeting the best interest of the participant and their experience of care. Schedule: 8:30AM – 5:30PM Weekly Hours: 40 QUALIFICATIONS: Education: Nursing Degree from an accredited institution. BSN required Experience: + Minimum of three to five (3 - 5+) years’ experience in a hospital or home care clinical setting. + Knowledgeable about Medicare and Medicaid guidelines. + Case Management and discharge planning experience is beneficial. + Two to three (2 - 3) years of Utilization Review experience at a Managed Care Organization is preferred. Other: + Proficient in computer programs such as Microsoft Office and Microsoft Excel a plus. + Excellent verbal and written communication skills. + Excellent problem solving and analytical skills. + Accurate attention to detail with strong organizational skills. + Demonstrated ability to manage multiple projects and be flexible. + Able to travel to any of the CLHC locations, as needed. Physical Requirements Individuals must be able to sustain specific physical requirements essential to the job. This includes, but is not limited to: + Standing – duration of up to 6 hours a day. + Sitting/Stationary positions – sedentary position for up to 6-8 hours a day for consecutive hours/periods of time. + Lifting/Push/Pull – up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely, using OSHA guidelines, etc. + Bending/Squatting – have to be able to bend or squat to care for patients safely, use medical supplies, etc. + Stairs/Steps/Walking/Climbing – must be able to maneuver stairs safely, climb up/down and walk to access work areas Position requires an individual to be able to travel, walk between sites/locations and work areas throughout the day. + Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (i.e., typing, use of medical supplies, equipment, etc.) + Sight/Visual Requirements – must be able to visually assess patients, read orders and type/write documentation, etc., accurately. + Audio Hearing and Motor Skills (language) Requirements – must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. + Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job. Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company. We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Salary Range (Min-Max):$105,000.00 - $112,000.00