Referral and Prior Authorization Rep III

University of Rochester•Town of Brighton, NY

20h•$20 - $26•Onsite

About The Position

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. This role serves as the patient referral and prior authorization specialist, with oversight of data and compliance to enterprise standards and referral and prior authorization guidelines. The specialist communicates regularly with patients, families, clinical and non-clinical staff, identifying barriers to appointment compliance, insurance company barriers, and tracking all assistance provided. This position is accountable for planning, execution, appeals, and efficient follow-through on all aspects of the process, which has a direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care, and follow-up. The specialist adheres to approved protocols for working referrals and prior authorizations and makes decisions that are guided by protocols and practices requiring some interpretation, maintaining an expert-level understanding of the department/division. May train new staff members.

Requirements

High School Diploma required
Minimum of two years of relevant experience required, or an equivalent combination of education and experience.
Demonstrated customer relations skills required.

Nice To Haves

Medical Terminology
Experiences with appointment scheduling software
Electronic medical records

Responsibilities

Managing department referrals and serving as a liaison, appointment coordinator, and patient advocate between the referring office, specialists, and patient to assist in the coordination of scheduled visits and procedures.
Incorporating all incoming referrals to the department using Epic Referral work queues.
Conducting data analyses to track patient compliance with specialty services, consistently monitoring work queues and communicating with referring and referred-to departments to reconcile discrepancies and/or answer questions.
Escalating case management when medical assessment is needed.
Prioritizing referral requests using medical protocols, responding immediately and expediting most urgent requests.
Requesting and coordinating team and patient meetings as needed or requested by patient.
Participating as an active member of the care team.
Acquiring insurance authorization for visits and, if applicable, any testing, entering insurance authorization information in the Epic referral record for the patient, and attaching referral records to any visits in which they are missing.
Documenting all communications pertaining to the referral and/or insurance authorization in the notes section of the Epic referral record.
Performing a needs assessment using information from the electronic medical record to assure the appropriate appointment/procedure is scheduled with the appropriate provider, ensuring that accurate patient demographic and current insurance information is captured, and adhering to RIM protocols for record verification.
Performing complex appointment scheduling, linking referrals and ancillary services for the assigned specialty service.
Providing patients with appointment and provider information, directions to the office location, and any educational materials if appropriate.
Providing regular data to the team on patient compliance with treatment plans and strategies to improve patient compliance, which includes provider template oversight and reporting to the manager any obstacles to timely scheduling.
Ensuring ancillary testing and other specialty referrals have been executed and results received and acted upon as needed.
Investigating failure to receive such information, troubleshooting, resolving, and/or making recommendations to ensure delivery/receipt.
Preparing and providing multiple, complex details to insurance or worker’s compensation carrier to obtain prior authorizations for both standard and complex requests such as imaging, non-invasive procedures, sleep studies etc.
Communicating medical information to the insurance carrier and coordinating peer-to-peer reviews for denied services.
Anticipating insurer’s various questions and preparing requests by applying prior insurer decisions and specialty/sub-specialty knowledge of general medical experience and terminology, specialty and sub-specialty medical office experience, International Classification of Diseases (ICD) and Current Procedure Technology (CPT), insurance policies, permissible and non-permissible requests, necessary and appropriate medical terminology to use in order for claim to be approved, previous treatments that are necessary to report, and appropriate verbiage for treatments that have been tried and not successful.
Resolving obstacles presented by the insurance company by applying knowledge and experience of previous authorization requests, denials, and approvals.
Persevering with the process to ensure as many applications are approved as possible without provider intervention.
Determining relevant information needed, based on previous authorization request experience for submission to carrier if first or second request is denied.
Collaborating with provider to draft and finalize letter of medical necessity.
Using system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
Reviewing complex referral requests, evaluating and scheduling to the appropriate provider.
Working with providers and other clinical staff to establish the best care plan for the patient.
Serving as backup to the PSR scheduling team when short staffed, vacations, etc.
Processing outgoing referrals and discussing with patient options for outside URMC options for care.
Assuring Meaningful Use requirements are met.
Ensuring that the Summary of Care was transferred electronically via Epic to the referred-to office; if the Summary of Care was not or cannot be transferred via Epic, taking additional steps to get this information to the referred-to office either via facsimile or mail.
Processing incoming referrals not generated within the UR system.
Completing referral entry for all external referrals into Epic following approved protocols.
Coordinating any ancillary testing and obtaining any outside records needed for patient appointment.
Other duties as assigned