Referral and Prior Authorization Rep III

University of Rochester; United States; On-site; USD 26,000 - 36,000; Full time

Job summary

The University of Rochester is seeking a patient referral and prior authorization specialist for the Vascular Surgery department in Rochester, NY. You will manage referrals, coordinate appointments, and ensure timely insurance authorization using Epic Referral workflows.

You will communicate with patients, families, and clinical staff, troubleshoot barriers to scheduling, and maintain compliance with enterprise standards and local policies. This is a full-time, onsite role in Rochester.

Qualifications

• Experience with patient referrals and prior authorization processes.
• Ability to analyze data related to scheduling and authorizations.
• Familiarity with Epic Referral workflows and EMR systems.

Responsibilities

• Manage department referrals as liaison and appointment coordinator.
• Obtain insurance authorization and track referral/authorization status.
• Communicate with patients, families, and staff to resolve scheduling barriers.
• Train new staff on referral and authorization processes.

Skills

Referral coordination

Prior authorization

Data analysis

Epic EMR

Patient communication

Tools

Epic EMR

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):

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

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

400137 Vascular Surgery

Work Shift:

UR - Day (United States of America)

Range:

UR URCA 205 H

Compensation Range:

$19.62 - $26.49

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.

Responsibilities:

Serves as the patient referral and prior authorization specialist, with oversight of data and 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. Accountable for planning, execution, appeals, and efficient follow-through on all aspects of the process, which has a direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care, and follow-up. Adheres to approved protocols for working referrals and prior authorizations. Makes decisions that are guided by protocols and practices requiring some interpretation; maintains an expert-level understanding of the department/division. May train new staff members.

ESSENTIAL FUNCTIONS

Referral:

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 using Epic Referral work queues. 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. Acquire insurance authorization for the visit and, if applicable, any testing; insurance authorization information will be entered in the Epic referral record for the patient, 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 Epic referral record.

Performs a needs assessment using information from the electronic medical record to assure the appropriate appointment/procedure is schedule with the appropriate provider; ensuring that accurate patient demographic and current insurance information is captured; 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 which includes 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 insure delivery/receipt.

Prior Authorization:

Prior authorization functionality required for testing and services ordered by referred to specialist includes, preparing and providing 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., c ommunicating 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 sp