Referral Coordinator
Company: BrightonOne
Role summary
Referral Coordinator is a full-time role at BrightonOne in Boston, Massachusetts, United States (hybrid). Posted 2026-10-03. Salary: USD 60,000–70,000 per year. Experience level: 0-2. No degree required.
- Job title
- Referral Coordinator
- Company
- BrightonOne
- Location
- Boston, Massachusetts, United States
- Work arrangement
- hybrid
- Employment type
- full-time
- Category
- Healthcare Support
- Salary
- USD 60,000–70,000 per year
- Experience level
- 0-2
- Degree required
- No
- Date posted
- 2026-10-03
This is a great opportunity to get into patient care coordination without a degree! You'll earn a good salary while helping patients access the care they need, with the added perk of a hybrid work schedule.
Job description
Description
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
Position Overview
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.
Key Responsibilities
Referral & Authorization Processing
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.
Eligibility & Benefit Verification
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.
Clinical Escalation
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.
Member & Provider Support
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.
Documentation & Service Recovery
Accurately document all referral activity and communications within plan systems, maintaining data integrity.
Maintain member confidentiality in compliance with HIPAA and organizational privacy policies.
Support resolution of member concerns and coordinate with internal departments to close the loop on outstanding needs.
Clinical Operations & Administrative Support
Utilization Management: Complete case intake and setup in the UM platform, obtain medical records and clinical information from providers, prepare determination and notification letters, and track cases against turnaround-time requirements.
Case and Care Management: Process incoming case management referrals, conduct non-clinical outreach and scheduling, and prepare member mailings and educational materials.
Quality: Support HEDIS and quality improvement activities, including medical record requests and retrieval, care-gap outreach, and data collection.
Compliance & Accreditation: Assist in preparing case files and documentation for internal audits, inter-rater reliability activities, appeals, and DHA oversight and accreditation reviews (URAC).
Clinical Operations: Maintain trackers, logs, and reports; prepare meeting materials and minutes; update desk procedures and job aids; and support special projects as assigned.
Requirements
Qualifications
Education & Experience
High school diploma or equivalent required; Associate's degree or relevant post-secondary coursework preferred.
1 or more years of experience in a healthcare, health plan, or medical office setting, ideally in referrals, prior authorizations, utilization or care management support, scheduling, or member/patient services.
Experience with benefit verification and healthcare administrative workflows.
Experience within a TRICARE, USFHP, Medicare Advantage, Medicaid, or other HMO/capitated managed care organization preferred.
Experience with referral/authorization or care management platforms and knowledge of CPT/ICD coding basics preferred.
Skills & Competencies
Strong customer-service orientation and professional written and verbal communication skills.
High attention to detail and accura