Referral and Prior Auth Specialist
Performs complex patient referrals and prior authorization duties, in a fast-paced environment with minimal direction and considerable latitude for independent judgment in the Division of Plastic Surgery. 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. Serves as primary support to Referral Coordinator for management, triaging, and scheduling of incoming new patient request referrals. May train new staff members.
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 and consistently monitors the work queues including the Missing Referral Queue 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.
Acts as primary support to Referral Coordinator for management, triaging, and scheduling of incoming new patient request referrals.
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 outside of UR imaging, non-invasive procedures, general testing, surgeries, new patient and follow-up clinic visits 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.
Other Office Management :
Receives incoming patient telephone calls for surgeon(s) and nurse practitioner(s), managing and/or resolving various scheduling/coordination issues and answering questions as needed. Coordinate scheduling of patients at multiple practice sites; coordinates referrals for consults. Obtains patient medical records to facilitate patient care. Documents telephone calls into Record. Triages telephone calls from patients and referring physicians to surgeons, residents and nurse practitioners.
Coordinates work with nurse practitioner(s). Manages all incoming mail for surgeon(s) and nurse practitioner(s) assuring that all correspondence receives timely attention and is followed up appropriately. Coordinates transfer of patient studies to and from other hospitals and physician offices. Assists with department hiring processes by training incoming staff when requested. Scans patient information into Onbase. Functional knowledge of various office equipment. Provides coverage for absences within the division, off-site practice location, and within the department when requested.
Other duties as assigned.
High School Diploma required
Associates degree in Medical, Secretarial, billing or related field preferred.
2 years of relevant experience required; or an equivalent combination of education and experience required.
Medical Terminology, experiences with surgical/appointment scheduling software, and electronic medical records, preferred.
Excellent interpersonal skills, customer service skills and organizational skills preferred.
Strong attention to detail and communication skills, including written communication preferred.
Working knowledge of word processing and spreadsheet applications preferred.
Experience in medical office setting preferred. eRecord, Cadence and medical terminology 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 Apply
All applicants must apply online.
EOE Minorities/Females/Protected Veterans/Disabled
Pay Range: $ 18.50 - $ 24.71 Hourly
The 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.
Location: Medical Faculty Group
Full/Part Time: Full-Time
Opening: Full Time 40 hours Grade 009 Plastic Surgery