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University of Rochester Prior Authorization Specialist - 227554 in Rochester, New York

Prior Authorization Specialist Job ID 227554

Location Central Administration Full/Part Time Full-Time Favorite Job Regular/Temporary Regular Opening

Full Time 40 hours Grade 009 University Health Service

Responsibilities

Position Summary:

With minimum direction and considerable latitude for independent judgement, 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 on patient scheduling, treatment, care and follow up.

Supervision and Direction Received:

Receives minimal direction from physician, mid-level providers, Billing Manager and or Director for Administration.

Supervision and Direction Exercised:

Responsible for monitoring his/her own performance on assigned tasks to insure compliance with office policies and procedures as requested by management. Also responsible for modification of such policies and periodic process improvement adjustments as needed to comply with carrier demand.

Provides direction to and coordinates training activities for scheduling staff and medical office assistants as needed.

Machines and equipment used:

Standard office equipment including but not limited to computer, telephone, facsimile. Will use software for electronic medical record system, student information system and internal share drive. Also requires knowledge and use of web based carrier tools.

Typical Duties:

Requests and obtains prior authorizations for services including but not limited to: Long acting reversible contraceptives, HPV vaccines, Physical therapy and Mental Health, from third party insurance carriers using phone, fax and web based processes. Provides additional information to carriers upon request; escalating requests to management or Care manager when higher level of coding or clinical input is required. Updates clinical staff, patient and electronic health record with reference information and authorization status. (30%)

Identifies potential coverage and payment issues prior to the procedure being performed. Resolves issues and notifies department management when satisfactory resolution cannot be obtained, alerting physicians, office staff and/or patients in a timely manner to avoid further conflict. Follows through on matters requiring additional action to the point of resolution with special detail to scheduled procedure dates. (20%)

Researches and verifies all levels of insurance coverage for all procedures performed by UHS providers by contacting third party payers via telephone, website or form submission. Determines eligibility for services based on policy effective dates, coverage of benefits, authorization requirements and provider contractual participation. (15%)

Manages referral process for Students by responding to tasks, verbal or written request to initiate, fax or follow up on external provider referrals. (10%)

Using knowledge and understanding of various insurance plans, counsels patients on potential out of pocket expenses based on insurance coverage, referral/prior-authorization requirements and provider network participation. (10%)

Develops, utilizes and modifies tracking mechanisms to ensure all approvals are obtained prior to procedure being performed. (5%)

Participates in monitoring process compliance of scheduling staff and medical office assistants as it pertains to prior authorization requests and responses. Provides input in regards to performance evaluations and recruiting of supportive staff. (5%)

Provides coverage for other areas of the department as needed and as scheduling allows. (5%)

Other duties as requested.

Qualification:

Associates 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. Demonstrated customer relations, medical terminology, experience with electronic health records, insurance verification and patient/provider communication skills strongly preferred.

Note: This document only describes typical duties and responsibilities. Other functions and tasks will be assigned as required by the supervisor and may include assignment to a satellite office.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

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