POSITION SUMMARY: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. Candidate must demonstrate capability and desire to work independently and be a strong team player. Demonstrates ICARE values in each of the major responsibilities (ICARE—an acronym for Integrity, Inclusion, Compassion, Accountability, Respect and Excellence—provides the foundation for how we treat people at this Medical Center). Achieving our strategic vision depends on all of us living out these values and embracing the diversity of our faculty, staff, students, trainees and patients.TYPICAL DUTIES:
Responsible for managing referrals for the divisions of Pediatric Allergy/Immunology and Rheumatology. 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.
Acquires insurance authorization and/or testing for the visit(s). Enter patient insurance authorization information into the Epic referral record, conduct quality audits to ensure referral records are complete. Documents all communications pertaining to the referral and/or insurance authorization in the notes section of the Epic referral record.
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.
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.
Demonstrates medical knowledge base with ability 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. Assures Meaningful Use requirements are met. Ensures that the Summary of Care was transferred electronically via Epic to the referred-by 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-by office either via facsimile or mail.
Knowledgeable of the current policies of the major payers for the relevant clinic-administered drugs that require prior authorization (PA), and will be responsible for working with the clinic providers, nurses and other patient care staff to assure that all required elements of the policy are applicable in advance of requesting PA. Take primary responsibility for submitting PA requests to the payers for clinic-administered drugs, and managing the submission of any supplemental information that is requested.
Review all denials for PA to determine the reason the request was denied and preparing a response to the payer with necessary additional information. If the denial management will need to involve other clinic staff or providers, the required individuals will be engaged and a summary of all actions taken to date along with supporting documentation will be provided.
Notify the relevant provider and provide the physician with needed documentation and summary of actions taken to date, if a letter of medical necessity is needed or if physician-to-medical director conversation is needed for approval outside of the payer policy.
Document all PAs in the appropriate location within the electronic medical record include the PA number and dates of approval. Track all PAs to assure that they are renewed on a timely basis to prevent interruptions or delays in treatment.
Performs a needs assessment using information from the electronic medical record to assure the appropriate appointment/procedure is scheduled 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.
Reviews provider templates regularly, reporting any obstacles to timely scheduling to manager. 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 ensure delivery/receipt.
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.
QUALIFICATIONS:
High School diploma or equivalent and 2 years of relevant experience, or equivalent combination of education and experience required.
Demonstrated customer relations skills required.
2 years related work experience; or an equivalent combination of education and experience required.
Medical Terminology, experience with electronic medical records and patient access and revenue cycle systems preferred.
Must prioritize exceptional patient care with compassion and respect. Demonstrated customer service skills, specifically strong oral and written communication skills. Medical Terminology, experience with surgical/appointment scheduling software (such as Flowcast), ERecord and Microsoft Office. Demonstrate accuracy in all correspondence including eRecord. Ability to work in a fast-paced, stressful environment, and demonstrate efficiency in prioritizing assignments while working successfully with a team.
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: $19.47 - $25.77 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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