Referral & Prior Authorization Specialist III

University of Rochester•Minneapolis, MN

7d•$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 position serves as the patient referral specialist, with oversight of data and compliance to enterprise standards and referral guidelines. The specialist communicates regularly with patients, families, clinical and non-clinical staff, identifying barriers to appointment compliance and insurance company barriers, and tracking all assistance provided. This role is accountable for planning, execution, appeals, and efficient follow-through on all aspects of the referral process, which has a direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care, and follow-up. The specialist adheres to approved protocols for working referrals and makes decisions guided by protocols and practices requiring some interpretation, maintaining an expert-level understanding of the department/division. May train new staff members.

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
Experience with electronic medical records

Responsibilities

Manage department referrals, serving as a liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients.
Coordinate scheduled visits and procedures, incorporating all incoming referrals into the department using Epic Referral work queues.
Conduct data analyses to track patient compliance with specialty services, monitor work queues, and communicate with referring and referred-to departments to reconcile discrepancies.
Escalate case management when medical assessment is needed.
Prioritize referral requests using medical protocols, responding immediately and expediting urgent requests.
Request and coordinate team and patient meetings as needed or requested by the patient.
Participate as an active member of the care team.
Acquire insurance authorization for visits and testing, entering authorization information into the Epic referral record and attaching referral records to missing visits.
Document all communications pertaining to referrals and/or insurance authorization in the Epic referral record.
Perform needs assessments using the electronic medical record to ensure appropriate appointment/procedure scheduling with the correct provider.
Ensure accurate patient demographic and current insurance information is captured, adhering to RIM protocols for record verification.
Perform complex appointment scheduling, linking referrals and ancillary services for the assigned specialty service.
Provide patients with appointment and provider information, directions, and educational materials.
Provide regular data to the team on patient compliance with treatment plans and strategies to improve compliance, including provider template oversight and reporting obstacles to timely scheduling.
Ensure ancillary testing and other specialty referrals have been executed and results received and acted upon.
Investigate failure to receive information, troubleshoot, resolve issues, and/or make recommendations for delivery/receipt.
Demonstrate expert medical knowledge to recognize urgent clinical situations.
Review complex referral requests, evaluate, and schedule to the appropriate provider.
Work with providers and clinical staff to establish the best care plan for the patient.
Serve as backup to the PSS scheduling team during short staffing or vacations.
Process outgoing referrals, discussing outside URMC care options with patients.
Ensure Meaningful Use requirements are met and that the Summary of Care was transferred electronically via Epic to the referred-to office, taking additional steps if necessary.
Process incoming referrals not generated within the UR system, completing referral entry into Epic following approved protocols.
Coordinate ancillary testing and obtain outside records needed for patient appointments.
Perform other duties as assigned.