Referral & Prior Auth Rep III

University of Rochester; San Antonio (TX); On-site; USD 57,859,000 - 78,523,000; Full time

Job summary

The University of Rochester is seeking a dedicated referrals and scheduling specialist to support the CVSL RCPG & Cardiac Rehab department in Rochester, NY. You will coordinate referrals, manage prior authorizations, and serve as a patient advocate, ensuring accurate scheduling and effective communication with patients and providers.

You will handle complex insurance interactions, verify patient information, and assist with documentation in the electronic health record to support timely care

Responsibilities

• Oversees data and ensures compliance to enterprise standards and referral and prior authorization guidelines.
• Communicates regularly with patients, families, clinical and non-clinical staff to identify barriers to appointment compliance and insurance issues.
• Plans, executes, appeals and follows through on all aspects of the process affecting scheduling, care and follow up.
• Prepares and provides complex details to insurance or workers' compensation carriers to obtain prior authorizations.

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):

60 Corporate Woods, Suite 100, Rochester, New York, United States of America, 14623

Opening:

Worker Subtype:
Regular
Time Type:
Full time
Scheduled Weekly Hours:
40
Department:
500708 CVSL RCPG & Cardiac Rehab
Work Shift:
UR - Day (United States of America)
Range:
UR URCA 205 H
Compensation Range:
$20.30 - $27.41

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

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.

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 know