Referral & prior auth rep iii Job at University of Rochester (Rochester)

Job Description

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Responsibility

Oversees data and ensures 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
Plans, executes, appeals and follows through on all aspects of the process which has direct, multifaceted impact on patient scheduling, treatment, care and follow up
Adheres to approved protocols for working referrals and prior authorizations
Responsible for managing department referrals
Serves as liaison, appointment coordinator, and patient advocate between the referring office, specialists, and patient to assist in the coordination of scheduled visits and procedures incorporating all incoming referrals to the department
Conducts data analyses to track patient compliance with specialty services, consistently monitors the work queues, and communicates with referring and referred to departments to reconcile any discrepancies and/or answer any questions
Escalates case management when medical assessment is needed
Prioritizes referral requests using medical protocols, responding immediately and expediting most urgent requests
Requests and coordinates team and patient meetings as needed or requested by patient
Participates as an active member of the care team
Acquires insurance authorization for the visit and, if applicable, any testing and attaches referral records to any visits in which they are missing
Documents all communications pertaining to the referral and/or insurance authorization in the notes section of the electronic health record referral record
Performs a needs assessment using information from the electronic medical record to ensure the appropriate appointment/procedure is scheduled with the appropriate provider, ensuring accurate patient demographic and current insurance information is captured and adheres to RIM protocols for record verification
May perform complex appointment scheduling, linking referrals, and ancillary services for the assigned specialty service
Provides patients with appointment and provider information, directions to the office location, and any educational materials if appropriate
Provides regular data to team on patient compliance with treatment plans and strategies to improve patient compliance, including provider template oversight, reporting to manager any obstacles to timely scheduling
Ensures ancillary testing and other specialty referrals have been executed and results received and acted upon as needed
Investigates failure to receive such information, troubleshoots, resolves, and/or makes recommendations to ensure delivery/receipt
Prepares and provides 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
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
Applies 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 provider to draft and finalize letter of medical necessity
Uses system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival
Manages orders for patients being seen in ED/ Urgent Care
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
Processes outgoing referrals
Discusses options with patient for outside URMC care
Ensures Meaningful Use requirements are met
Ensures 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, takes additional steps to get this information to the referred to office either via facsimile or mail
Processes incoming referrals not generated within the UR system
Completes referral entry for all external referrals into electronic health record following approved protocols
Coordinates any ancillary testing and obtains any outside records needed for patient appointment
Other duties as assigned

Requirements

High School diploma or equivalent and 2 years of relevant experience required
Medical Terminology, experience with surgical/appointment scheduling software and electronic medical records preferred
Demonstrated customer relations skills required

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Referral & prior auth rep iii

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