Referral & Prior Auth Rep III

Rochester, NY


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.


Referral Management

  1. Participates as an active member of the care team primarily responsible for managing department referrals to include but not limited to incoming (internal / external) and outgoing referrals. Serves as liaison, appointment coordinator, and patient advocate between the referring office to assist in the coordination of scheduled visits and procedures using Epic Referral work queues.

  2. 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.

  3. Provides patients with appointment and provider information, directions to the office location and any educational materials if appropriate.

  4. Monitors and reports any obstacles to manager and care team to timely scheduling on patient compliance with treatment plans and participates in the development of strategies to improve patient compliance.

  5. Documents all communications pertaining to the referral and/or insurance authorization in the notes section of the Epic referral record.

Prior Authorization

  1. 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.

  2. Acquire insurance authorization for the visit and, if applicable, any testing; insurance authorization information will be entered in the Epic referral record for the patient, and attaches referral records to any visits in which they are missing.

  3. 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).

  4. Applies knowledge and protocols to varying degrees based on how complexities of the situation deviate from the norm.

  5. Resolves obstacles presented by the insurance company by applying knowledge and experience of previous authorization requests, denials and approvals.

  6. On behalf of the provider and the University, perseveres with the process to ensure as many applications are approved as possible without provider intervention.

  7. Determines relevant information needed, based on previous authorization request experience for submission to carrier if first or second request is denied.

  8. 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.

Referral and Prior Authorization Tracking

  1. Manages orders for patients being seen in ED/ Urgent Care

  2. Coordinates any ancillary testing and other specialty referrals, obtains any outside records needed for patient appointments and confirms referrals have been executed and results received and acted upon as needed

  3. Conducts daily review of referral queues to track patient compliance with specialty services and communicates with referring and referred to departments to reconcile any discrepancies and/or answer any questions.

  4. Performs a needs assessment using information from the electronic medical record to assure the appropriate appointment/procedure is schedule with the appropriate provider; ensuring that accurate patient demographic and current insurance information is captured; adheres to RIM protocols for record verification.

  5. Escalates case management when medical assessment is needed.

Patient Scheduling

  1. Assist with schedule procedures and office appointments for patients at multiple locations using electronic scheduling systems.

  2. Extensive use of electronic medical record system to correspond with attending physicians, midlevel providers, patients, internal customers, external provider’s offices, and others regarding the status of patient requests for appointments.

  3. Accurately communicate to patients various preparation requirements for GI procedures and other appointments in writing, by telephone, and electronically.

  4. Consistently monitoring schedules for opportunities to improve all provider’s productivity and increase appointment availability and access for our patients.

Other duties as assigned


  • High school diploma or equivalent required.

  • Associates degree in Medical, Secretarial, billing or related field preferred.

  • 2 year of experience or equivalent combination of education and experience required.

  • Demonstrated customer service skills preferred.

  • Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records, 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: $ 18.89 - $ 25.51 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