Referral & Prior Auth Rep III-Imaging

University of Rochester•Town of Brighton, NY

4d•$20 - $27•Onsite

About The Position

The Referral & Prior Auth Rep III-Imaging oversees referral and prior authorization data and ensures compliance with enterprise standards and applicable guidelines. The role communicates with patients, families, clinical and non-clinical staff, and insurers to identify barriers to appointments, coordinate care, and track assistance provided. It plans, executes, appeals, and follows through on referrals and authorizations that affect patient scheduling, treatment, care, and follow-up, following approved protocols. The representative manages department referrals and serves as a liaison, appointment coordinator, and patient advocate among referring offices, specialists, and patients. Responsibilities include monitoring work queues, analyzing and reporting patient compliance, prioritizing and coordinating appointments and procedures, assessing needs using electronic medical records, ensuring accurate demographic and insurance information, acquiring authorizations, and documenting communications. The role coordinates ancillary testing and records, troubleshoots missing information, and escalates cases when medical assessment is needed. The position prepares complex prior authorization requests for imaging and other services, communicates medical information to insurance carriers, coordinates peer-to-peer reviews for denials, and collaborates with providers on letters of medical necessity. It also manages orders for patients seen in the ED or Urgent Care, processes outgoing and external incoming referrals, transfers summaries of care to referred-to offices, and performs other duties as assigned.

Requirements

High school diploma or equivalent and 2 years of relevant experience, or an equivalent combination of education and experience.
Demonstrated customer relations skills.
Ability to manage referrals and prior authorizations and communicate with patients, providers, clinical staff, and insurance carriers.
Ability to prioritize urgent referral requests and recognize urgent clinical situations.

Nice To Haves

Medical terminology.
Experience with surgical or appointment scheduling software.
Experience with electronic medical records.

Responsibilities

Oversee referral and prior authorization data and ensure compliance with enterprise standards, guidelines, and approved protocols.
Communicate with patients, families, clinical and non-clinical staff, referring offices, specialists, and insurers; identify barriers and track assistance provided.
Manage department referrals and coordinate scheduled visits and procedures as a liaison, appointment coordinator, and patient advocate.
Analyze patient compliance with specialty services, monitor work queues, reconcile discrepancies, and report obstacles to timely scheduling.
Prioritize referral requests using medical protocols and expedite urgent requests; escalate cases when medical assessment is needed.
Coordinate team and patient meetings as needed and participate as an active member of the care team.
Obtain insurance authorization for visits, testing, and procedures; attach missing referral records and document communications in the electronic health record.
Assess appointment and procedure needs using the electronic medical record; ensure appropriate provider selection, accurate demographic and insurance information, and adherence to RIM record-verification protocols.
Schedule complex appointments, link referrals and ancillary services, and provide patients with appointment details, directions, and educational materials as appropriate.
Provide the team with compliance data and strategies to improve adherence to treatment plans, including provider template oversight.
Ensure ancillary testing and specialty referrals are completed, results are received and acted upon, and investigate and troubleshoot missing information.
Prepare and submit complex prior authorization requests, communicate medical information to insurers, and coordinate peer-to-peer reviews for denied services.
Apply specialty and sub-specialty knowledge, medical terminology, ICD and CPT knowledge, insurance policies, and prior authorization experience to requests and denials.
Collaborate with providers to draft and finalize letters of medical necessity and track renewals and approvals before patient arrival.
Manage orders for patients seen in the ED or Urgent Care, recognize urgent clinical situations, review complex referrals, and coordinate care plans with providers and clinical staff.
Process outgoing referrals, discuss outside URMC care options with patients, meet Meaningful Use requirements, and ensure the Summary of Care reaches the referred-to office through Epic, fax, or mail.
Process incoming referrals from outside the UR system, enter them into the electronic health record following approved protocols, and coordinate ancillary testing and outside records.
Perform other duties as assigned.