Referral & Prior Auth Rep III

University of Rochester•Town of Brighton, NY

22h•Onsite

About The Position

The Referral & Prior Auth Rep III at the University of Rochester plays a critical role in patient care coordination, ensuring compliance with enterprise standards and referral/prior authorization guidelines. This position involves extensive communication with patients, families, and clinical/non-clinical staff to identify and overcome barriers to appointment compliance and insurance issues. The representative is responsible for planning, executing, appealing, and following through on all aspects of the referral and prior authorization process, which directly impacts patient scheduling, treatment, care, and follow-up. Key functions include managing department referrals, serving as a patient liaison and advocate, conducting data analyses on patient compliance, acquiring insurance authorizations for visits and testing, and documenting all communications in the electronic health record. The role also involves complex appointment scheduling, preparing detailed information for insurance carriers to obtain prior authorizations, and resolving obstacles presented by insurance companies. The representative must apply medical knowledge, ICD and CPT codes, and insurance policy understanding to ensure approvals, and collaborate with providers for letters of medical necessity. Additionally, the role manages orders for ED/Urgent Care patients, processes both incoming and outgoing referrals, and ensures Meaningful Use requirements are met.

Requirements

High School diploma or equivalent
2 years of relevant experience
Demonstrated customer relations skills

Nice To Haves

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

Responsibilities

Oversees data and ensures 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.
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.
Adheres to approved protocols for working referrals and prior authorizations.
Responsible for managing department 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.
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.
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 the visit and, if applicable, any testing 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 electronic health record referral record.
Performs a needs assessment using information from the electronic medical record to ensure the appropriate appointment/procedure is scheduled with the appropriate provider, ensuring accurate patient demographic and current insurance information is captured and 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.
Provides regular data to team on patient compliance with treatment plans and strategies to improve patient compliance, including provider template oversight, reporting to manager any obstacles to timely scheduling.
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 ensure delivery/receipt.
Prepares and provides 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.
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.
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 options with patient 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; if the Summary of Care was not or cannot be transferred via Epic, takes additional steps to get this information to the referred to office either via facsimile or mail.
Processes incoming referrals not generated within the UR system.
Completes referral entry for all external referrals into electronic health record following approved protocols.
Coordinates any ancillary testing and obtains any outside records needed for patient appointment.
Other duties as assigned.