Referral & Prior Auth Rep III

University of Rochester•Alabaster, AL

1d•$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, and staff to identify barriers to appointment compliance and insurance issues, while tracking all assistance provided. The position plans, executes, appeals, and follows through on all aspects of the referral and prior authorization process, which directly impacts patient scheduling, treatment, care, and follow-up. Adherence to approved protocols for managing 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, serving as a liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients to coordinate scheduled visits and procedures.
Conducts data analyses to track patient compliance with specialty services, monitors work queues, and communicates with departments to reconcile discrepancies.
Escalates case management when medical assessment is needed.
Prioritizes referral requests using medical protocols, responding immediately and expediting urgent requests.
Coordinates team and patient meetings as needed.
Participates as an active member of the care team.
Acquires insurance authorization for visits and testing, and attaches referral records.
Documents all communications regarding referrals and insurance authorizations in the electronic health record.
Performs needs assessments to ensure appropriate appointments/procedures are scheduled with the correct providers, capturing accurate patient demographic and insurance information.
May perform complex appointment scheduling, linking referrals, and ancillary services.
Provides patients with appointment and provider information, directions, and educational materials.
Provides regular data to the team on patient compliance and strategies to improve it, reporting obstacles to timely scheduling to management.
Ensures ancillary testing and other specialty referrals are executed and results are received and acted upon, investigating and resolving any issues with information delivery/receipt.
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.
Applies knowledge of prior insurer decisions, medical terminology, ICD/CPT codes, insurance policies, and previous treatments to prepare requests and resolve obstacles presented by insurance companies.
Collaborates with providers to draft and finalize letters of medical necessity.
Uses system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
Manages orders for patients seen in ED/Urgent Care.
Reviews complex referral requests, evaluates, and schedules to the appropriate provider.
Works with providers and clinical staff to establish the best care plan for the patient.
Processes outgoing referrals, discusses options with patients for outside URMC care, and ensures Meaningful Use requirements are met.
Ensures the Summary of Care is transferred electronically via Epic or by facsimile/mail if electronic transfer is not possible.
Processes incoming referrals not generated within the UR system, completing referral entry into the electronic health record.
Coordinates ancillary testing and obtains outside records needed for patient appointments.
Performs other duties as assigned.