Referral and Prior Authorization Rep III

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.

Job Location (Full Address):

140 Canal View Blvd, Ste 103, Rochester, New York, United States of America, 14623

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

400137 Vascular Surgery

Work Shift:

UR - Day (United States of America)

Range:

UR URCA 205 H

Compensation Range:

$19.62 - $26.49

Responsibilities:

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 a 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.

ESSENTIAL FUNCTIONS

Referral:

• 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 using Epic Referral work queues. 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. Acquire insurance authorization for the visit and, if applicable, any testing; insurance authorization information will be entered in the Epic referral record for the patient, 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 Epic referral record.
• Performs a needs assessment using information from the electronic medical record to assure the appropriate appointment/procedure is schedule with the appropriate provider; ensuring that accurate patient demographic and current insurance information is captured; 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 which includes 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 insure delivery/receipt.

Prior Authorization:

• Prior authorization functionality required for testing and services ordered by referred to specialist includes, preparing and providing 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 (i.e., medication could not be utilized due to heart condition).  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.
• 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.
• Serves as backup to the PSR scheduling team when short staffed, vacations, etc.
• Processes outgoing referrals.  Discusses with patient options for outside URMC options for care. Assures Meaningful Use requirements are met.   Ensures that 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, additional steps will be taken 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 Epic following approved protocols.  Coordinates any ancillary testing and obtains any outside records needed for patient appointment.
• Other duties as assigned

MINIMUM EDUCATION & EXPERIENCE

• High School Diploma required
• Minimum of two years of relevant experience required, or an equivalent combination of education and experience.
• Medical Terminology, experiences with appointment scheduling software and electronic medical records preferred.

KNOWLEDGE, SKILLS AND ABILITIES

• Demonstrated customer relations skills required.

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.