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University of Rochester Referral Coordinator & Prior Authorization Spec - 228102 in Rochester, New York

Referral Coordinator & Prior Authorization Spec Job ID 228102

Location Medical Faculty Group Full/Part Time Full-Time Favorite Job Regular/Temporary Regular Opening

Full Time 40 hours Grade 009 Orthopaedic Appt Ctr


7:00 AM - 7:00 PM


Job Summary:

With minimal 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. In addition, this role holds "expert-level" knowledge of the daily workflows and centralization efforts, including consistently and regularly identifying areas of improvement and establishing employee goals while demonstrating ICARE values.

Duties and Responsibilities:

Uses independent judgment to examine, research and assemble necessary patient information via the scheduling system and multiple areas of the electronic medical record. 30%

  • Prepares and provides multiple, complex details and facts to insurance carrier or worker's compensation carrier to obtain prior authorizations for New Patient requests while utilizing various Referral Workqueues.

  • Communication and collaboration with insurance companies based on required authorizations and able to anticipate insurer's various questions to prepare requests 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

  • Shares new information regarding best practices

  • Nuances of various insurance carders

  • Applies above listed knowledge and protocols to varying degrees based on how complexities of the situation deviate from the norm.

    Proficient with phone etiquette and scheduling practices within the department of Orthopaedics. Demonstrates appropriate utilization o: scheduling guidelines and verbiage to patients, providers, insurance carriers and PCP offices. Utilized as a resource for insurance and scheduling questions. 25%

    Resolves obstacles presented by the primary care offices or insurance companies 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. 20%

    Determines relevant information needed, based on previous authorization request experience for submission to carrier if first or second request is denied. Collaboration with the Billing manager and staff to further gain additional knowledge and resources regarding authorizations for visits. 15%

    Develops and utilizes and modifies cracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival. 10%

    Minimum Qualifications:

    Associate's degree in Medical, Secretarial, billing or related field, or a minimum of two years of relevant experience required; or an equivalent combination of education and experience. Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records, preferred. Demonstrated customer relations skills.

    How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled