Referral & Prior Auth Rep III

University of Rochester

4d • $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, 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.
• Requests and 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 pertaining to referrals and insurance authorization in the electronic health record.
• Performs needs assessments to ensure appropriate appointments/procedures are scheduled with the correct provider, 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 the manager.
• 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 questions and prepares requests by applying prior insurer decisions and specialty knowledge.
• Resolves obstacles presented by insurance companies by applying knowledge of previous authorization requests, denials, and approvals.
• 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 being 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.
• Ensures Meaningful Use requirements are met and Summary of Care is transferred electronically via Epic.
• 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.

Benefits

• The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED