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University of Rochester Referral & Prior Auth Spec - 231163 in Rochester, New York

Referral & Prior Auth Spec Job ID 231163

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

Full Time 40 hours Grade 009 Pediatric Adolescent Med

Schedule

8:00 AM-4:30 PM

Responsibilities

GENERAL PURPOSE:

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. May train new staff members.

RESPONSIBILITIES:

  • 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, non-invasive procedures, sleep studies 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.

  • Manages orders for patients being seen in ED/ Urgent Care. Demonstrates expert medical knowledge base with ability to recognize urgent clinical situations. Prioritizes referral requests, responding immediately and expediting most urgent requests. Reviews complex

  • referral requests, evaluates and schedules to the appropriate provider. Works with providers and other clinical staff to establish the best care plan for the patient. Processes outgoing referrals. Discusses with patient options for outside URMC options for care. Assures Meaningful Use requirements are met. Ensures that the Summary of Care was transferred electronically via Epic to the referred to office; if the Summary of Care was not or cannot be transferred via Epic, additional steps will be taken to get this information to the referred to office either via facsimile or mail. Processes incoming referrals not generated within the UR system. Completes referral entry for all external referrals into Epic following approved protocols. Coordinates any ancillary testing and obtains any outside records needed for patient appointment.

  • Answers incoming calls routing them as appropriate, scheduling appointments as necessary

  • Other duties as assigned

QUALIFICATIONS:

  • High School Diploma or equivalent required

  • Associate‚Äôs Degree in Medical, Secretarial or related Field required

  • 3 years of relevant experience required or an equivalent combination of education and experience required

  • Ability to work effectively with individuals across the age range (5-30 years old) with multiple health issues across 3 different divisions. Flexible in approach and appreciates the demands of a fast-paced, constantly evolving practices. Can work with individuals with varying levels of need and complexity. Comfortable working with pilot and novel programs to create new opportunities for integrated service models required.

    How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

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