[Hiring] Referral and Prior Auth Rep-Imaging @University of Rochester

Role Description

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.

Essential Functions

• Responsible for managing department referrals.
• Serves as liaison, appointment coordinator, and patient advocate between the referring office, specialists, and patient.
• Conducts data analyses to track patient compliance with specialty services.
• Consistently monitors the work queues and communicates with referring and referred to departments.
• Escalates case management when medical assessment is needed.
• Prioritizes referral requests using medical protocols.
• Requests and coordinates team and patient meetings as needed.
• Participates as an active member of the care team.
• Acquires insurance authorization for visits and testing.
• Documents all communications pertaining to referrals and insurance authorizations.
• Performs needs assessments using information from the electronic medical record.
• May perform complex appointment scheduling and linking referrals.
• Provides patients with appointment and provider information, directions, and educational materials.
• Provides regular data to team on patient compliance with treatment plans.
• Ensures ancillary testing and specialty referrals have been executed and results received.
• Investigates failure to receive information and troubleshoots issues.
• Prepares and provides details to insurance or worker’s compensation carriers for prior authorizations.
• Anticipates insurer’s questions and prepares requests accordingly.
• Resolves obstacles presented by the insurance company.
• Determines relevant information needed for submission to carriers.
• Collaborates with providers to draft letters of medical necessity.
• Uses system tracking mechanisms to ensure all renewals/approvals are obtained.
• Manages orders for patients being seen in ED/Urgent Care.
• Demonstrates expert medical knowledge base with ability to recognize urgent clinical situations.
• Processes outgoing referrals and discusses options with patients for outside care.
• Ensures Meaningful Use requirements are met.
• Processes incoming referrals not generated within the UR system.
• Completes referral entry for all external referrals into electronic health record.
• Coordinates any ancillary testing and obtains outside records needed for patient appointments.
• Other duties as assigned.

Qualifications

• High School diploma or equivalent and 2 years of relevant experience required.
• Or equivalent combination of education and experience.
• Medical Terminology, experience with surgical/appointment scheduling software and electronic medical records preferred.

Requirements

• Demonstrated customer relations skills required.

Benefits

• Compensation Range: $20.30 - $27.41.
• Full-time position with scheduled weekly hours of 40.