Referral & Prior Auth Rep III

University of Rochester•City of Rochester, NY

4d•$20 - $27•Onsite

About The Position

The Referral & Prior Auth Rep III oversees referral and prior authorization data and ensures compliance with enterprise standards and applicable guidelines. The role communicates with patients, families, and clinical and non-clinical staff to identify barriers to appointments and insurance approval, track assistance provided, and manage processes that affect patient scheduling, treatment, care, and follow-up. The representative follows approved protocols for referrals and prior authorizations and is an active member of the care team. The position manages department referrals, coordinates visits and procedures, monitors work queues and patient compliance, prioritizes requests using medical protocols, and escalates cases requiring medical assessment. It secures insurance authorization, ensures referral records and relevant information are attached to visits, and documents communications in the electronic health record. It also assesses patient needs, schedules appropriate appointments and procedures, coordinates ancillary services and testing, and provides patients with appointment information and educational materials as appropriate. The role prepares and submits standard and complex prior authorization requests, communicates with insurance carriers, coordinates peer-to-peer reviews for denied services, and collaborates with providers on letters of medical necessity. It also manages urgent and emergency department referral orders, outgoing and external referrals, and the transfer or delivery of required records and summaries to referred-to offices.

Requirements

High school diploma or equivalent and two years of relevant experience, or an equivalent combination of education and experience.
Demonstrated customer relations skills.

Nice To Haves

Medical terminology.
Experience with surgical or appointment scheduling software.
Experience with electronic medical records.

Responsibilities

Manage department referrals and serve as liaison, appointment coordinator, and patient advocate among referring offices, specialists, and patients.
Analyze and track patient compliance with specialty services, monitor work queues, and coordinate with departments to resolve discrepancies and answer questions.
Prioritize referral requests using medical protocols, expedite urgent requests, and escalate cases when medical assessment is needed.
Arrange team and patient meetings as needed and participate as an active member of the care team.
Obtain insurance authorization for visits and applicable testing, and attach missing referral records to visits.
Document referral and insurance authorization communications in the electronic health record.
Assess patient needs using the electronic medical record and schedule appropriate appointments or procedures with the appropriate provider.
Verify accurate patient demographic and current insurance information in accordance with RIM protocols.
Perform complex appointment scheduling and coordinate linked referrals and ancillary services for the assigned specialty service.
Provide patients with appointment and provider information, office directions, and educational materials when appropriate.
Share data on patient compliance and strategies to improve compliance, oversee provider templates, and report barriers to timely scheduling to the manager.
Ensure ancillary testing and specialty referrals are completed and results are received and acted upon; investigate and resolve failures in delivery or receipt.
Prepare and submit standard and complex prior authorization requests to insurance or workers’ compensation carriers.
Communicate medical information to insurers and coordinate peer-to-peer reviews for denied services.
Use medical terminology, specialty knowledge, insurer policies, and prior authorization experience to address insurer questions and resolve obstacles.
Determine relevant information for resubmissions after denials and collaborate with providers to draft and finalize letters of medical necessity.
Track authorization renewals and approvals to ensure they are obtained before patient arrival.
Manage orders for patients seen in the emergency department or urgent care, recognize urgent clinical situations, and coordinate appropriate care plans with providers and clinical staff.
Process outgoing referrals, discuss outside-URMC care options with patients, and ensure Meaningful Use requirements and Summary of Care transfers are completed.
Process incoming referrals from outside the UR system, enter them into the electronic health record according to approved protocols, and coordinate ancillary testing and outside records.
Perform other duties as assigned.