University of Rochester Referral & Prior Authorization Spec - 223625 in Rochester, New York
Referral & Prior Authorization Spec
Strong Memorial Hospital
Full Time 40 hours Grade 009 SMH Med Oncology Interlakes
With minimum 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.
SUPERVISION AND DIRECTION RECEIVED:
Receives minimal direction from Physician, Advanced Practice Providers, Executive Director and/or or Administrator II , Administrator I, Administrative Assistant. ls responsible for independently planning, executing and evaluating own work.
SUPERVISION AND DIRECTION EXERCISED:
May train and coordinate activities of peers or support staff.
MACHINES AND EQUIPMENT USED:
Standard office equipment includingcomputer, calculator, telephone, facsimile. Will use software for electronic medical record system, appointment scheduling system, and other systems as needed.
Uses independent judgment to examine, research and assemble necessary patient information via the scheduling system and multiple areas of the electronic medical record. Decides, based on previous authorization approvals and denial experience, the relevant information to be included inthe request.
Prepares and provides multiple, complex details and facts to insurance carrier or worker's compensation carrier to obtain prior
authorizations for both standard and complex requests such as invasive procedures but also for medication, imaging, non-invasive procedures, etc.
Anticipates insurer's various questions and prepares request 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 oflntemational Classification of Diseases (ICO) 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, and
Appropriate verbiage for treatments that have been tried and not successful, ie., medication could not be utilized due to heart condition.
Shares new infonnation regardingbest practices with providers, executive director. administrator and administrative assistant and OAS team.
Applies above listed knowledge and protocols to varying degrees based on how complexitiesof 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 infonnation needed. based on previous authorization request experience for submission to carrier if first or second request is denied. Collaborates with provider, if necessary, to draft and finalize letter of medical necessity.
Develops and utilizes and modifies tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
May participate in recruiting, hiring and promotion decisions. May complete performance evaluations. May monitor staff performance.
Other Known Responsibilities:
Timely response to and management of Interlakes provider requests;
Veterans Administration prior authorizations;
Securing Free-Drug and its management;
Home Health Certification and Inpatient Visit monthly reports;
Submit claims to AFLAC upon patient request.
Associate' s degree in Medical, Secretarial or related field and a minimum of three years of relevant billing experience required· or an equjvalent combination of education and experience. Medical Tenninology, experiences with appointment scheduling software, e.g. ePARC, and electroruc medical records, preferred. Demonstrated customer relations skills.
How To Apply
All applicants must apply online.
EOE Minorities/Females/Protected Veterans/Disabled