General Summary The Insurance, Eligibility & Referral Clerk is responsible for referral processing, insurance eligibility verification, prior authorization and physician referral management, scheduling initial evaluations and Individualized Family Service Plan (IFSP) meetings, and maintaining accurate client records in the Electronic Health Record (EHR) and state-required database systems. This position ensures compliance with agency policies, insurance requirements, and applicable federal and state regulations while supporting timely access to Early Childhood Intervention (ECI) services.

Primary Responsibilities Referral Intake and Scheduling:

Process referrals from receipt through enrollment from physicians, hospitals, community agencies, families, and other referral sources, maintaining accurate referral status, outcomes, and required documentation in the EHR and state-required database systems. Verify referral, demographic, and insurance information with families and referral sources. Educate families regarding the ECI program, enrollment process, available services, and next steps. Schedule initial evaluations and Individualized Family Service Plan (IFSP) meetings and provide required family notifications and documentation. Confirm IFSP appointments based on provider availability and accessibility; ensure new or rescheduled appointments are booked at least 24 hours in advance without disrupting existing client schedules, and fill vacancies to maximize provider availability and minimize service delays.

Insurance Eligibility and Authorization:

Verify insurance eligibility and benefits through insurance carrier portals and direct communication with insurance carriers. Obtain, submit, and follow up on prior authorizations, physician referrals, and supporting documentation required for timely service delivery, including communication with primary care providers as needed. Discuss insurance coverage, authorization status, and estimated financial responsibility with parents or legal guardians. Collect, review, scan, and maintain insurance cards, Third-Party Payer documentation, and other eligibility-related documents in the EHR, ensuring accuracy, completeness, and timely receipt. Maintain current prior authorization and insurance tracking logs, including eligibility, authorizations, physician referrals, renewals, expiration dates, and follow-up activities.

Documentation and Data Management:

Maintain accurate and current client demographic, insurance, referral, scheduling, and authorization records by entering, updating, and reviewing information in the EHR and state-required database systems. Communicate incomplete or missing client information and documentation to supervisor to ensure timely follow-up and processing. Maintain compliance with agency policies and procedures, insurance requirements, HIPAA, and applicable federal and state regulations.

Compliance and Quality Assurance:

Adhere to federal ECI performance indicators, including the required 45-day timeline from referral through enrollment and applicable post-referral processing timeframes. Prioritize daily workload to complete referrals, insurance verification, authorizations, scheduling, and documentation within established agency and regulatory timeframes. Identify and communicate delays, missing documentation, insurance issues, scheduling conflicts, or other barriers that may impact timely service delivery or regulatory compliance and escalate unresolved concerns to supervisor. Assist with audits, quality assurance reviews, data validation, and performance reporting as requested. Promotes and adheres to CACOST core values (Accountability, Excellence, Integrity, Quality, and Teamwork). Performs any other duties as assigned. Work Experience Required Minimum two (2) years of experience in insurance verification, healthcare intake, referral processing, or a related healthcare administrative position, including experience using EHR systems. Preferred Four (4) years of experience in healthcare insurance verification, referral management, patient access, or Early Childhood Intervention (ECI) services. Experience working with Electronic Health Record (EHR) systems and state-required reporting databases. Education/Certifications/Licensure Required High School Diploma or equivalent Skills Required Knowledge of insurance eligibility verification, prior authorizations, physician referrals, healthcare reimbursement, medical terminology, and healthcare administrative practices. Proficiency in Electronic Health Record (EHR) systems, Microsoft Office Suite, and other electronic recordkeeping systems. Strong organizational, time management, communication, and customer service skills, with the ability to prioritize multiple responsibilities and maintain accurate, confidential records. Ability to work independently and collaboratively, identify and resolve problems, exercise sound judgment, and communicate or escalate issues to management when appropriate. Demonstrated commitment to professionalism, accuracy, confidentiality, and continuous quality improvement. Preferred Experience working with state-required reporting databases and healthcare information systems. Knowledge of Early Childhood Intervention (ECI) program requirements, federal performance indicators, and insurance authorization processes. Physical Requirements Light to medium physical duties include standing, walking, reaching, bending, hearing, and talking for up to eight (8) hours a day. Must have good vision, with or without corrective lenses. Must be able to lift twenty (20) pounds. Lifting will be primarily confined to occasional on-premises lifting of boxes of office supplies and minor office equipment.