Referral & Prior Auth Rep III

Rochester, NY

POSITION SUMMARY:

Serves as Dentistry’s Medicaid/Medicaid Managed Care prior authorization specialist, with oversight of data and compliance to enterprise standards and prior authorization guidelines. Accountable for communicating with departments clinical and non-clinical staff to obtain complete prior approval requests. 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 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 clinical and non-clinical staff members.

TYPICAL DUTIES:

  • Uses independent judgment to review, examine, research and apply

  • The Medicaid Dental Guidelines to approve or deny prior authorization request.

  • Uses previous authorization approvals and denial experience, for consistency in approval or denial process.

  • Anticipates insurer’s requirements and ensures the prepared request by applying prior decisions and specialty/sub-specialty knowledge of the following:

  • General dental experience and terminology as well as sub specialty dental office experience,

  • Extensive knowledge of Current Dental Technology codes and definitions (CDT)

  • Insurance policies

  • Permissible and non-permissible requests,

  • Necessary and appropriate dental terminology to use in order to approve claim.

  • 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 Medicaid Guidelines by applying knowledge and experience of previous authorization requests, denials and approvals. On behalf of the provider and EIOH, perseveres with the process to ensure as many applications are approved as possible.

  • Work with Administrator to develop process improvements, implement efficiencies and increase accuracy of prior approval process. Provides regular data to Administrator on department compliance.

Other duties as assigned.

QUALIFICATIONS:

  • High school degree and a minimum of three years of relevant dental experience required.

  • Dental Assistant or Associate’s degree in Dental, Medical, Secretarial or related field preferred.

  • Dental Terminology, Knowledge of Dental Medicaid Guidelines preferred.

  • Experience with electronic medical records preferred.

  • Demonstrated customer relations skills preferred.

  • Strong proficiency with Microsoft Office, including Word, Excel, Outlook, and PowerPoint preferred.

  • The individual should have the ability to work effectively with peers, leadership, and faculty; the ability to manage high volume of prior authorizations, maintain a high degree of confidentiality, prioritize duties and perform professionally under pressure and with limited direction. Must have excellent analytical and problem-solving skills, be very detail oriented, organized, self-motivated to follow through on requests, without requiring follow-up 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: $18.89 - $25.51 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.

Apply for Job

  • Careers

  • Sign In

  • New User

Location: Eastman Dental Center
Full/Part Time: Full-Time
Opening:
Schedule: