Referral & Prior Authorization III

University of Rochester

1d • $20 - $26 • 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 is responsible for managing department referrals and prior authorizations. The position serves as a liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients to facilitate the coordination of scheduled visits and procedures. Key responsibilities include conducting data analyses to track patient compliance, monitoring work queues, communicating with departments to resolve discrepancies, and escalating cases when medical assessment is needed. The role also involves prioritizing referral requests, acquiring insurance authorization, documenting communications in the electronic health record, performing needs assessments for scheduling, and providing patients with necessary information. Additionally, the position ensures ancillary testing and other specialty referrals are executed and results are received and acted upon, troubleshoots issues, and prepares complex details for insurance carriers to obtain prior authorizations. The Referral & Prior Authorization III demonstrates expert medical knowledge to recognize urgent clinical situations and works collaboratively with providers and clinical staff to establish optimal care plans. This role also processes incoming referrals not generated within the UR system and ensures Meaningful Use requirements are met, including the electronic transfer of the Summary of Care.

Requirements

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

Nice To Haves

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

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.

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