Referral & Prior Auth Rep III

University of Rochester•City of Rochester, NY

1d•$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 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
2 years of relevant experience required or equivalent combination of education and experience
Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records preferred
Demonstrated customer relations skills required.

Responsibilities

Serves as the patient referral and prior authorization specialist, with oversight of data and compliance to enterprise standards and referral and prior authorization guidelines.
Communicates regularly with patients, families, clinical and non-clinical staff, identifying barriers to appointment compliance, insurance company barriers and tracking all assistance provided.
Accountable for planning, execution, appeals and efficient follow through on all aspects of the process which has direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care and follow up.
Adheres to approved protocols for working referrals and prior authorizations.
Makes decisions that are guided by protocols and practices requiring some interpretation; maintains an expert level understanding of the department/division.
May train new staff members.
Responsible for managing Child Neurology Division referrals.
Serves as 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.
Conducts data analyses to track patient compliance with specialty services, consistently monitors the work queues and communicates with referring and referred to departments to reconcile any discrepancies and/or answer any questions.
Prioritizes referral requests using medical protocols, responding immediately and expediting most urgent requests.
Acquire insurance authorization for the visit and, if applicable, any testing; insurance authorization information will be entered in the Epic referral record for the patient, and attaches referral records to any visits in which they are missing.
Documents all communications pertaining to the referral and/or insurance authorization in the notes section of the Epic referral record.
Prior authorization functionality required for testing and services ordered by referred to specialist includes, 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.
Anticipates insurer’s various questions and prepares request 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, appropriate verbiage for treatments that have been tried and not successful (i.e., medication could not be utilized due to heart condition).
Applies knowledge and protocols to varying degrees based on how complexities of the situation deviate from the norm.
Resolves obstacles presented by the insurance company by applying knowledge and experience of previous authorization requests, denials and approvals.
On behalf of the provider and the University, perseveres with the process to ensure as many applications are approved as possible without provider intervention.
Determines relevant information needed, based on previous authorization request experience for submission to carrier if first or second request is denied.
Collaborates with provider to draft and finalize letter of medical necessity.
Uses system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
Performs a needs assessment using information from the electronic medical record to assure the appropriate appointment/procedure is schedule with the appropriate provider; ensuring that accurate patient demographic and current insurance information is captured; adheres to RIM protocols for record verification.
May perform complex appointment scheduling, linking referrals and ancillary services for the assigned specialty service.
Provides patients with appointment and provider information, directions to the office location and any educational materials if appropriate.
Ensures ancillary testing and other specialty referrals have been executed and results received and acted upon as needed.
Investigates failure to receive such information, troubleshoots, resolves, and/or makes recommendations to insure delivery/receipt.
Manages orders for patients being seen in ED/ Urgent Care.
Demonstrates expert medical knowledge base with ability to recognize urgent clinical situations.
Prioritizes referral requests, responding immediately and expediting most urgent requests.
Reviews complex referral requests, evaluates and schedules to the appropriate provider.
Works with providers and other clinical staff to establish the best care plan for the patient.
Processes outgoing referrals.
Discusses with patient options for outside URMC options for care.
Other job duties as assigned.