Referral & Prior Auth Rep IV

Rochester, NY

GENERAL PURPOSE:

Oversees and provides direction to team of Referral Prior Authorization Representatives. Provides direction and supervision to adhere to enterprise standards of referral and prior authorization guidelines. Accountable for planning, execution, and efficient follow through on all aspects of the processes which has direct, multifaceted impact (quality, financial, patient satisfaction) on patient scheduling, treatment, care, and follow up. Makes decisions that are guided by protocols and practices requiring some interpretation; maintains an expert level understanding of the department/division. Trains new staff members, resolve problems and issues, monitors quality assurance of daily operations, and provide coaching and training support.

JOB DUTIES AND RESPONSIBILITIES:

  • Responsible for managing and coordinating daily assignments for the department team of Referral & Prior Authorization Representatives. Serves as liaison and focal point for answering questions and solving problems for difficult and unusual referrals/authorizations, assists in problem identification, quantification, and resolution. Performs quality assurance monitoring for activities completed in area of immediate responsibility as well of other areas that affect it using systems reporting. Monitors work queues and measures quality, quantity, and timeliness of tasks performed. Prepares related logs and management reports. Communicates routinely to relay accuracy to staff and manager. Escalates case management when further action is needed. Requests, coordinates, prepares, and presents at team meetings.

  • Implements and monitors procedures for enhancing levels of service and quality. Develops guidelines for prioritizing and assigning work activities, evaluating effectiveness, and modifying processes as necessary. Routinely updates established guidelines and workflows based on insurer rules/regulation changes, new clinic sites/providers, system/departmental workflow changes. Assures ongoing communication with the provider/patient as any concerns are identified.

  • Performs all duties of Referral Prior Authorization Representatives as required/necessary, in addition to assisting with more complex requests. Achieves and maintains proficiency in provision of excellent customer service, accuracy, and efficiency of work. Participates as an active member of the team when staff absences occur to assure staffing needs are met.

  • Applies knowledge and protocols to varying degrees based on how complexities of the situation deviate from the norm. Resolves obstacles presented by applying knowledge and experience of previous authorization requests, denials, and approvals.

  • Participates in recruiting, hiring and promotion decisions. Assists in completing performance evaluations. Promptly and accurately completes required documentation related to hires, terminations, and other status changes. Monitors staff performance; counsels’ staff regarding performance issues. Adjusts staff schedule and duties as necessary using experienced judgment. Manages and approves staff requests for time off and overtime.

  • Provides training to Referral Prior Authorization Representatives on all aspects of work, including the following:

  • Electronic medical record system support

  • External database system support

  • Patient record review

  • Knowledge of provider subspecialties

  • Collection of additional information from provider to submit to insurance carrier when needed.

  • Acts as information resource. Attends educational programs for department at direction of supervisor and teaches other staff. Attends routine and ad hoc meetings both within the department and system wide as requested. Participates in project management within department and system wide as requested.

  • Collaborates with other Referral and Prior Authorization Representatives across programs to establish best practice standards. Disseminates those standards and implements and monitors the adherence to those standards. Reports 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 a liaison to community for any issues.

Other duties as assigned

QUALIFICATIONS:

  • High School diploma, Associate Degree in Medical or Secretarial or related field required.

  • 3 years of relevant experience required.

  • 1 year of demonstrated leadership experience required.

  • or equivalent combination of education and experience required.

  • Medical Terminology, experience with electronic medical records preferred.

  • Demonstrated customer relations skills required.

  • Attention to detail preferred.

  • Strong verbal and written communication skills preferred.

  • Excellent organizational and computer skills preferred.

  • Possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers preferred.

  • Knowledge of ICD-10 and CPT codes preferred.

  • Prior experience in completing Prior Authorizations via phone or insurance payor platforms 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: $19.71 - $26.61 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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