University of Rochester Prior Authorization Spec in Rochester, New York
Full Time 40 hours Grade 009 Imaging Sciences-Pre Auth
With minimum direction and considerable latitude for independent judgment, obtains prior authorizations for both standard and complex requests. Provides multiple and complex details to insurance carrier by anticipating their questions when reviewing and retrieving relevant information from the electronic medical record. Is 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.
- Uses independent judgment to examine, research and assemble necessary patient information via the scheduling system and multiple areas of the electronic medical record. Decides, based on previous authorization approvals and denial experience, the relevant information to be included in the request.
- Prepares and provides multiple, complex details and facts to insurance carrier or worker’s compensation carrier to obtain prior authorizations for both standard and complex requests such as invasive procedures and complicated surgeries but also for medication, imaging, non-invasive procedures, sleep studies etc.
- Anticipates insurer’s various questions and prepares request by applying prior insurer decisions and specialty/sub-specialty knowledge of the following:
- General medical experience and terminology as well as specialty and sub specialty medical office experience,
- Extensive knowledge of 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, and
- Appropriate verbiage for treatments that have been tried and not successful (i.e., medication could not be utilized due to heart condition).
- Shares new information regarding best practices.
Applies above listed 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.
- Develops and utilizes and modifies tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
- Participates in recruiting, hiring and promotion decisions. Completes performance evaluations. Monitors staff performance.
Associate’s degree in Medical, Secretarial or related field and a minimum of three years of relevant experience required; or an equivalent combination of education and experience. Medical Terminology, experiences with surgical/appointment scheduling software (such as Flowcast), and electronic medical records, preferred. Demonstrated customer relations skills.
EOE Minorities/Females/Protected Veterans/Disabled
Job Title: Prior Authorization Spec
Location: Strong Memorial Hospital
Job ID: 208699
Full/Part Time: Full-Time