[Hiring] Referral & Prior Auth Rep III @University of Rochester

Role Description

Serves as the patient referral and prior authorization specialist, with oversight of data and 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. Accountable for planning, execution, appeals and efficient follow through on all aspects of the process which has direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care and follow up. Adheres to approved protocols for working referrals and prior authorizations. Makes decisions that are guided by protocols and practices requiring some interpretation; maintains an expert level understanding of the department/division. May train new staff members.

Responsibilities

• Prior Authorizations:
  • Prepare and provide multiple, complex details to insurance or worker’s compensation carrier to obtain prior authorizations for both standard and complex requests.
  • Communicate medical information to the insurance carrier and coordinate peer-to-peer reviews for denied services.
  • Anticipate insurer’s various questions and prepare requests by applying prior insurer decisions and specialty/sub-specialty knowledge.
  • Resolve obstacles presented by the insurance company by applying knowledge and experience of previous authorization requests, denials, and approvals.
  • Collaborate with provider to draft and finalize letter of medical necessity.
  • Use system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
• Referral Management:
  • Assist in managing Adult Neurology Division imaging referrals.
  • Serve as liaison, appointment coordinator, and patient advocate between the specialists and patient.
  • Conduct data analyses to track patient compliance with specialty services.
  • Prioritize imaging requests using medical protocols and respond immediately to urgent requests.
  • Document all communications pertaining to imaging and/or insurance authorization in the notes section of the Epic referral record.
  • Perform needs assessment using information from the electronic medical record to assure appropriate scheduling.
  • Ensure ancillary testing and other specialty referrals have been executed and results received.
  • Manage orders for patients being seen in ED/Urgent Care.
  • Process outgoing referrals and discuss options for outside URMC options for care.
• Other job duties as assigned.

Qualifications

• High School diploma or an equivalent combination of education and experience required.
• A minimum of two years of relevant experience required or equivalent combination of education and experience.

Knowledge, Skills and Abilities

• Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records preferred.
• Demonstrated customer relations skills required.

Compensation

• Compensation Range: $19.62 - $26.49.
• The referenced pay range represents the minimum and maximum compensation for this job.

Company Description

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.