University of Rochester Prior Authorization Spec - 223606 in Rochester, New York
Prior Authorization Spec
Medical Faculty Group
Full Time 40 hours Grade 009 Pediatrics Endrocrinology
8:00 AM - 4:30 PM
With minimum direction and considerable latitude for independent judgment, obtains prior authorizations and/or referral information 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. Position works with a team of 4-6 staff to support approximately 30 physicians and mid-level providers in the multiple Divisions. Candidate must demonstrate capability and desire to work independently and be a strong team player. Demonstrates ICARE* values in each of the major responsibilities.
Uses independent judgment to examine, research and assemble necessary patient information via Flowcast and eRecord. Decides, based on previous authorization approvals and denial experience, the relevant information to be included in the request.
Prepares and provides multiple, complex details and facts to insurance carrier to obtain prior authorizations for both standard and complex requests.
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 sub specialty medical office experience,
Extensive knowledge of International Classification of Diseases (ICD) and Current Procedure Technology (CPT),
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
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 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 care team to draft and finalize letter of medical necessity.
Provides guidance to patients and their families in cases where insurance carrier denies application repeatedly and works with the families to try to resolve issues.
Develops, utilizes and modifies tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.
Shares new information regarding best practices with Administrator and staff. Ensures understanding of best practices and changes with payers by providing appropriate training.
Patient Scheduling/Phone Coverage:
Interacts with patients, families, providers and other customers on the telephone and in person. Must demonstrate ability to timely answer and efficiently triage incoming calls, determine nature/urgency of the call, and handle appropriately. Must be able to communicate effectively and relay information correctly and efficiently in a complex medical environment. Candidate will be cross trained and work closely with staff in Divisions of Adolescent Medicine, Pediatric Endocrinology and Pediatric Infectious Diseases.
Responsible for scheduling new and follow up appointments. Develop and work “bump” and reminder lists effectively, timely and accurately.
Must be able to navigate and use the EMR to document patient-related calls. Information must be concise, accurate and grammatically correct.
Upon completion of prior authorization process, schedule lab/genetic testing visit for patients.
Responsible for ordering, monitoring and submitting billing for specialty orders for Endocrinology patients as well as ordering specialty supplies for gynecology patients
Work with Administrator and staff to develop process improvements, implement efficiencies and increase accuracy of office functions.
Errands, mail, copies and other various duties as assigned.
Associate’s degree in Medical, Secretarial or related field and a minimum of three years of relevant experience required; or an equivalent combination of education and experience. Medical Terminology, experiences with surgical/appointment scheduling software (such as Flowcast), and electronic medical records, preferred. Demonstrated customer relations skills.
Demonstrated customer service skills, specifically strong oral and written communication skills, are essential. Knowledge of eRecord, Flowcast and Microsoft Office programs are desired. For qualified candidates, training will be provided. Candidate must demonstrate accuracy in all correspondence including eRecord. Candidate must be able to work in a fast-paced, stressful environment, demonstrate efficiency in prioritizing assignments, and be able to multi-task. Candidate should be skilled in proactively resolving problems and recommending and implementing continuous quality improvement. Candidate must be flexible with work schedule.
Monday through Friday, 8:00 a.m. – 4:30 p.m.
NOTE: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.
Training / Certification Expectations:
Flowcast and e-Record
Telephone, computer, printer, scanner, copier, fax, label printer and multifunction device. Will use software for eRecord (electronic medical record), Flowcast (scheduling) and other systems as needed.
System Access Requirements:
How To Apply
All applicants must apply online.
EOE Minorities/Females/Protected Veterans/Disabled