Referral & Prior Auth Spec

Rochester, NY

POSITION SUMMARY:

The Referral and Prior Authorization Specialist serves as the point person and subject matter expert to ensure optimization of patient referral and prior authorization coordination, and provider and client satisfaction. Includes oversight of data and compliance to enterprise standards and referral guidelines. Communicates regularly with patients, families, clinical and non-clinical staff, identifying barriers to appointment compliance, and tracking all assistance provided. Responsible for managing department referrals; consistently monitoring the EPIC work queues; communicating with referring and referred to departments to reconcile any discrepancies and/or answer any questions. Approved protocols for working referrals will be adhered to. The Division has two clinical locations, outpatient clinic for general GI and hepatology patients at Clinton Crossing Medical Complex and the Pediatric Advance Nutrition Support (PANS) and Pediatric Transplant clinic at the Ambulatory Care Center at the Golisano Children’s Hospital. The position interfaces with the different divisions throughout the Department of Pediatrics and other practices. Demonstrates ICARE* values in each of the major responsibilities

TYPICAL DUTIES:

Incoming Referral Processing

Processing of all incoming referrals to the department using the Receiving Authorized Referrals work queue. Following the approved protocol, employee will contact patients to schedule an appointment. If patient cannot be reached, continued following of protocol will be used to leave and denote messages left and finally retuning of the referral to the referring department with notation as to the reason for return. Employee will make multiple attempts to contact the patient, using different phone numbers if necessary and documenting all activities related to the referral.

Will utilize above average knowledge of Specialty diagnoses to be able to appropriately schedule patients with the provider most suitable to see them.

  • Referrals will be evaluated for appropriateness

  • Referrals will be evaluated for insurance appropriateness; coordinator will have an above average understanding of referral and insurance needs

  • Patients needing referrals will be communicated to the referring department

  • Be able to decide those referrals that are truly urgent and those that can wait for next available scheduling. Will make multiple attempts within the same day to contact patients and notate all efforts in eRecord.

Referral and Prior Authorization Specialist manage work queues as a mechanism to ensure all renewals/approvals are obtained prior to patient arrival.

Outgoing Referral Processing

Processing of the outgoing referrals taking the appropriate steps to obtain any necessary authorization. Employee will consult with providers as necessary to resolve any denied requests. Employee will maintain an ongoing record of work done on the referrals, ensuring that each referral is managed and will release the referral once all criteria for scheduling is met.

  • Referrals will be evaluated for insurance appropriateness; coordinator will have an above average understanding of referral and insurance needs

  • Employee will communicate all necessary medical information to the insurance carrier

  • Employee will coordinate peer-to-peer reviews with insurance carriers and providers as necessary

Outside UR System Referrals

Process incoming and outgoing referrals not generated within the U of R system; referrals are received via fax or mail; referral is reviewed for appropriateness, appointment is scheduled, communication with the referring office if appropriate and all necessary paperwork scanned to eRecord.

  • Ensure 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

  • Completes referral entry for all external referrals into Epic following approved protocols

Prior Authorization

Referral and Prior Authorization Specialist manage work queues as a mechanism to ensure all renewals/approvals are obtained prior to patient arrival.

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 in the 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 for procedures, medications, and appointments.

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,

  • Insurance policies,

  • Permissible and non-permissible requests,

  • Necessary and appropriate medical terminology to use in order for claim to be approved,

  • Coordinates and managers all Peer to Peer requests from the insurance company using electronic tools

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.

Referral and Prior Authorization Specialist manage work queues as a mechanism to ensure all renewals/approvals are obtained prior to patient arrival.

Other duties as assigned by Administrator, may be required to training coworkers.

QUALIFICATIONS:

  • High School Diploma and a minimum of two years of relevant experience required, or an equivalent combination of education and experience. Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records, preferred. Demonstrated customer relations skills.

  • Minimum of two years of relevant experience required

  • Extensive knowledge of International Classification of Diseases (ICD) and Current Procedure Technology (CPT),

  • Medical Terminology, Demonstrated customer service skills, specifically strong oral and written communication skills. Knowledge of eRecord and Microsoft Office programs. Ability to work in a fast-paced, stressful environment, demonstrate efficiency in prioritizing assignments, and be able to multi-task 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

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $ 18.50 - $ 24.71 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.

Location: Strong Memorial Hospital
Full/Part Time: Full-Time
Schedule: 8 AM-4:30 PM