ResponsibilitiesPosition SummaryServes 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. Serves as a critical member of the department to provider support to areas in need and provicer direction to team members and serve as a point of contact for questions and problem solving. Will assist with training new staff and develop department process and procedures related to referral and prior authorization responsibilities.Typical DutiesPrior Authorizatons:
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.
Referral Management:
Manage and oversee the prior authorization process for procedures, specialty office visits, VA (Veterans Affairs) referrals, and outside radiology appointments. Verify patient insurance information as it relates to obtaining PA’s. Serves as liaison, appointment coordinator, and patient advocate between the specialists and patient to assist in the coordination of scheduled visits and procedures incorporating all incoming imaging orders to the department using Epic Imaging Pools. Conducts data analyses to track patient compliance with specialty services, consistently monitors the imaging pools and communicates with providers to reconcile any discrepancies and/or answer any questions. Prioritizes imgaging requests using medical protocols, responding immediately and expediting most urgent requests. Acquire insurance authorization for the visit and, if applicable, any testing; insurance authorization information will be entered in the Epic for the patient. Documents all communications pertaining to the imgaing and/or insurance authorization in the notes section of the Epic referral record.
Provides training to other staff on all aspects of referral work, including electronic medical system support, patient record review, appointment and/or ancillary test scheduling, procedural scheduling, knowledge of provider sub-specialties and collection of additional information from provider or electronic medical system to submit to insurance carrier when needed.
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. 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 with patient options for outside URMC options for care.
Other job duties as assigned.Qualifications
High School diploma or equivalent and 2 years of relevant experience required
Or equivalent combination of education and experience required
1 year of demonstrated leadership experience required
Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records preferred
Demonstrated customer relations skills preferred
The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion 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 status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.How To ApplyAll applicants must apply online.EOE Minorities/Females/Protected Veterans/DisabledPay RangePay Range: $18.00 - $23.81 HourlyThe referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job’s compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.Apply for Job
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Location: Strong Memorial Hospital
Full/Part Time: Part-Time
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