Referral and Prior Authorization Rep III

Job Location: 140 Canal View Blvd, Ste 103, Rochester, New York, United States of America, 14623

Full-time, 40 scheduled weekly hours

Compensation Range: $19.62 - $26.49 per hour

Responsibilities

• Serves as the patient referral and prior authorization specialist, with oversight of data and compliance to enterprise standards and referral/prior authorization guidelines.
• Communicates regularly with patients, families, clinical and non-clinical staff to identify barriers to appointment compliance, insurance company barriers, and track all assistance provided.
• Accountable for planning, execution, appeals, and efficient follow-through on all aspects of the referral and prior authorization process, impacting patient scheduling, treatment, care, and follow-up.
• Adheres to approved protocols for working referrals and prior authorizations, making decisions guided by protocols requiring interpretation.
• Maintains an expert-level understanding of the department/division and may train new staff members.

Referral Essential Functions

• Manages department referrals, serving as liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients.
• Coordinates scheduled visits and procedures using Epic Referral work queues, incorporating all incoming referrals.
• Conducts data analyses to track patient compliance with specialty services, monitors work queues, and communicates with departments to reconcile discrepancies.
• Escalates case management when medical assessment is needed and prioritizes referral requests using medical protocols.
• Requests and coordinates team and patient meetings as needed, participating as an active member of the care team.
• Acquires insurance authorization for visits and testing, entering information in Epic and attaching referral records to visits.
• Documents all communications in the Epic referral record and performs needs assessments using electronic medical records.
• Ensures accurate patient demographic and insurance information is captured, adhering to RIM protocols for record verification.
• Performs complex appointment scheduling, linking referrals and ancillary services, and provides patients with appointment details and educational materials.
• Provides regular data on patient compliance with treatment plans and strategies to improve compliance, including provider template oversight.
• Ensures ancillary testing and specialty referrals are executed, results received, and acted upon; troubleshoots and resolves issues as needed.

Prior Authorization

• Prepares and provides complex details to insurance or worker’s compensation carriers to obtain prior authorizations for standard and complex requests (e.g., imaging, non-invasive procedures, sleep studies).
• Communicates medical information to insurance carriers and coordinates peer-to-peer reviews for denied services.
• Anticipates insurer questions and prepares requests using prior decisions, medical knowledge, and understanding of ICD/CPT codes, insurance policies, and medical terminology.
• Resolves insurance company obstacles using experience from previous authorization requests, denials, and approvals.
• Perseveres to ensure as many applications are approved as possible without provider intervention.
• Determines relevant information needed for resubmission if requests are denied and collaborates with providers to draft letters of medical necessity.
• Uses system tracking mechanisms to ensure renewals/approvals are obtained prior to patient arrival.
• Demonstrates expert medical knowledge to recognize urgent clinical situations and prioritizes requests accordingly.
• Reviews complex referral requests, evaluates, and schedules to the appropriate provider, working with clinical staff to establish care plans.
• Serves as backup to the PSR scheduling team during staff shortages.
• Processes outgoing referrals, discusses URMC care options with patients, and ensures Meaningful Use requirements are met.
• Ensures Summary of Care is transferred electronically via Epic or alternative methods (fax/mail) if necessary.
• Processes incoming referrals not generated within the UR system, completing referral entry in Epic and coordinating ancillary testing and outside records.

• Other duties as assigned.

Requirements

• High School Diploma required.
• Minimum of two years of relevant experience required, or an equivalent combination of education and experience.
• Medical Terminology, experience with appointment scheduling software, and electronic medical records preferred.

Skills

• Demonstrated customer relations skills required.