Referral & Prior Auth Rep III

University of Rochester•City of Rochester, NY

21h•$20 - $27•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 oversees data and ensures compliance to enterprise standards and referral and prior authorization guidelines. It involves regular communication with patients, families, clinical and non-clinical staff, identifying barriers to appointment compliance and insurance company barriers, and tracking all assistance provided. The position plans, executes, appeals, and follows through on all aspects of the process which has direct, multifaceted impact on patient scheduling, treatment, care, and follow-up. Adherence to approved protocols for working referrals and prior authorizations is essential.

Requirements

High School diploma or equivalent and 2 years of relevant experience required
Equivalent combination of education and experience
Demonstrated customer relations skills required

Nice To Haves

Medical Terminology
experience with surgical/appointment scheduling software
electronic medical records preferred

Responsibilities

Manages department referrals and serves 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.
Conducts data analyses to track patient compliance with specialty services, monitors work queues, and communicates with referring and referred-to departments to reconcile discrepancies.
Escalates case management when medical assessment is needed.
Prioritizes referral requests using medical protocols, responding immediately and expediting most urgent requests.
Requests and coordinates team and patient meetings as needed or requested by patient.
Participates as an active member of the care team.
Acquires insurance authorization for visits and testing, and attaches referral records.
Documents all communications pertaining to the referral and/or insurance authorization in the electronic health record.
Performs a needs assessment to ensure the appropriate appointment/procedure is scheduled with the appropriate provider, capturing accurate patient demographic and insurance information.
May perform complex appointment scheduling, linking referrals, and ancillary services for the assigned specialty service.
Provides patients with appointment and provider information, directions, and educational materials.
Provides regular data to the team on patient compliance with treatment plans and strategies to improve patient compliance.
Ensures ancillary testing and other specialty referrals have been executed and results received and acted upon.
Investigates failure to receive information, troubleshoots, resolves, and/or makes recommendations.
Prepares and provides complex details to insurance or worker’s compensation carriers to obtain prior authorizations for standard and complex requests.
Communicates medical information to insurance carriers and coordinates peer-to-peer reviews for denied services.
Anticipates insurer’s questions and prepares requests by applying prior insurer decisions and specialty/sub-specialty knowledge.
Resolves obstacles presented by the insurance company by applying knowledge and experience of previous authorization requests, denials, and approvals.
Perseveres with the process to ensure as many applications are approved as possible without provider intervention.
Determines relevant information needed for submission to a carrier if a request is denied.
Collaborates with the provider to draft and finalize a letter of medical necessity.
Uses system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
Manages orders for patients being seen in ED/ Urgent Care.
Demonstrates expert medical knowledge base with the ability to recognize urgent clinical situations.
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 options with patients for outside URMC care.
Ensures Meaningful Use requirements are met.
Ensures the Summary of Care was transferred electronically via Epic to the referred-to office, or takes additional steps to ensure transfer via facsimile or mail.
Processes incoming referrals not generated within the UR system.
Completes referral entry for all external referrals into the electronic health record.
Coordinates any ancillary testing and obtains any outside records needed for patient appointments.
Performs other duties as assigned.