Referral & Prior Auth Rep III

Job Location: 905 Culver Rd, Rochester, New York, United States of America, 14609

Full-time, regular position with a scheduled 40-hour work week during day shift.

Compensation range: $20.30 - $27.41 per hour.

Responsibilities

• Oversees data and ensures compliance with enterprise standards, referral, and 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.
• Plans, executes, appeals, and follows 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.

Essential Functions

• Manages department referrals, serving as liaison, appointment coordinator, and patient advocate between referring offices, specialists, and patients to coordinate scheduled visits and procedures.
• Conducts data analyses to track patient compliance with specialty services, monitors work queues, and communicates with departments to reconcile discrepancies or answer questions.
• Escalates case management when medical assessment is needed.
• Prioritizes referral requests using medical protocols, responding immediately to urgent requests.
• Requests and coordinates team and patient meetings as needed.
• Acquires insurance authorization for visits and testing, attaching referral records to visits where missing.
• Documents all communications related to referrals and insurance authorizations in the electronic health record.
• Performs needs assessments using electronic medical records to ensure appropriate appointments/procedures with accurate patient demographics and insurance information.
• May perform complex appointment scheduling, linking referrals, and ancillary services for assigned specialty services.
• Provides patients with appointment details, directions, and educational materials as appropriate.
• Provides regular data on patient compliance with treatment plans and strategies for improvement, including provider template oversight.
• Ensures ancillary testing and specialty referrals are executed, results received, and acted upon; troubleshoots any failures.
• Prepares and submits detailed prior authorization requests to insurance or workers' compensation carriers 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, ICD/CPT codes, and insurance policies.
• Resolves insurance obstacles using experience with previous authorization requests, denials, and approvals.
• Perseveres to secure approvals without provider intervention, determining relevant information for resubmission if denied.
• Collaborates with providers to draft letters of medical necessity.
• Uses system tracking mechanisms to ensure renewals/approvals are obtained prior to patient arrival.
• Manages orders for patients in ED/Urgent Care, demonstrating expert medical knowledge to recognize urgent clinical situations.
• Processes outgoing referrals, discusses 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 from external sources, entering them into the electronic health record and coordinating ancillary testing and outside records.
• Performs other duties as assigned.

Requirements

• High School diploma or equivalent and 2 years of relevant experience required.
• Equivalent combination of education and experience may be considered.
• Medical terminology, experience with surgical/appointment scheduling software, and electronic medical records preferred.

Skills

• Demonstrated customer relations skills.