Referral & Prior Auth Rep III - Strong West

Rochester, NY

POSITION SUMMARY:

With minimum direction and considerable latitude for independent judgement, obtains prior authorizations for both standard and complex requests. Provides multiple and complex details to insurance carriers 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 treatment, care and follow up.

TYPICAL DUTIES:

  • Uses independent judgement to examine, research and assemble necessary patient information via the patients’ medical record, scheduling system and multiple areas of the electronic medical record to submit authorization requests. Decides, based on previous authorization approvals and denials, the relevant information to be included in the request.

  • Prepares and provides multiple, complex details and facts to insurance carriers and Worker’s Compensation to obtain prior authorizations for both standard and complex requests such as take-home medications and complicated treatments like chemotherapies and other infusions.

  • Anticipates insurer’s various questions and prepares request by applying prior insurer decisions and specialty/sub-specialty knowledge of:

  1. General medical experience and terminology as well as specialty/sub-specialty medical office experience,

  2. Extensive knowledge of the International Classification of Diseases (ICD) and Current Procedure Technology (CPT),

  3. Insurance Policies

  4. Permissible and non- permissible requests

  5. Necessary and appropriate medical terminology to use in order for a request to be approved,

  6. Previous treatments (Step- Therapy) that is necessary for approval,

  7. Appropriate verbiage for treatments that have been tried and not successful (trial and failure or contraindications- i.e., medication could not be utilized due to heart condition),

  8. Shares new information regarding best practices.

  • Applies this 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 authorizations are approved as possible without provider intervention. If first or second request is denied, determines the relevant information needed, based on previous authorization request experience. Collaborates with the provider to draft and finalize letter of medical necessity.

  • Develops, utilizes and modifies tracking mechanisms to ensure all renewals and approvals are obtained prior to patient arrival

  • Responds in a timely manner to all eRecord messages with prior authorization status, when appropriate. Updates the requesting office of the outcome and provides methods of appeal when the authorization is denied. Scans all approvals and denials into the patient chart.

  • Assists in cross-coverage of the Medication Prior Authorization Department when necessary.

Other duties as assigned

QUALIFICATIONS:

  • High school diploma or equivalent required

  • Associates degree in Medical, Secretarial, billing or related field preferred

  • Minimum of 3 years of relevant experience required

  • or equivalent combination of education and experience required

  • Demonstrated customer service skills required

  • Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records, 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

Pay Range: $19.08 - $25.77 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.

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Location: Strong Memorial Hospital
Full/Part Time: Full-Time
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