Referral and Prior Auth Rep-Imaging

University of Rochester; Oregon; Hybrid; USD 28,000 - 38,000; Full time

Job summary

University of Rochester is seeking a Referral Coordinator to manage department referrals, coordinate appointments, and advocate for patients. The role includes obtaining insurance authorization, attaching referral records in the EMR, and supporting complex prior authorizations for imaging or procedures.

You will handle incoming and outgoing referrals, monitor patient compliance, and coordinate with providers and care teams to ensure timely scheduling and accurate record-keeping.

Qualifications

• High School diploma or equivalent and 2 years of relevant experience.
• Knowledge of medical terminology and scheduling software is preferred.
• Experience with electronic medical records is preferred.

Responsibilities

• Manage department referrals and coordinate appointments between offices, specialists, and patients.
• Obtain insurance authorization for visits and attach referrals to patient records.
• Prepare complex prior authorizations for imaging, procedures, or tests.
• Manage orders for patients in ED/Urgent Care and prioritize urgent referrals.
• Process incoming and outgoing referrals and ensure Proper documentation in EMR.
• Perform additional duties as assigned.

Skills

Data analysis

Referral coordination

Patient advocacy

Insurance authorization

EMR systems

Communication skills

Education

High School diploma

Equivalent education/experience

Tools

Epic EMR

Scheduling software

ICD/CPT knowledge

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 Location (Full Address): 120 Corporate Woods, Rochester, New York, United States of America, 14623

Opening:Worker Subtype: RegularTime Type: Full timeScheduled Weekly Hours: 40Department: 500351 Imaging Sciences-Pre AuthWork Shift: UR - Day (United States of America)Range: UR URCA 205 HCompensation Range: $20.30 - $27.41The 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.

ESSENTIAL FUNCTIONS

• 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.

MINIMUM EDUCATION & EXPERIENCE

• High School diploma or equivalent and 2 years of relevant experience required
• Or equivalent combination of education and experience
• Medical Terminology, experience with surgical/appointment scheduling software and electronic medical records preferred

KNOWLEDGE, SKILLS AND ABILITIES