Referral & Prior Auth Rep III

Opening

Full Time 40 hours Range URCC 204 OPD Pediatrics

Schedule

8 AM-4:30 PM

Responsibilities

GENERAL PURPOSE

With general direction and latitude for initiative and judgment performs routine and non- routine administrative duties to monitor and process department's referrals & prior authorizations. Is accountable for completing all referrals in a manner compliant with University standards.

Provides multiple and complex details to insurance carrier by anticipating their questions when reviewing and retrieving relevant information from the electronic medical record. Is accountable for planning, execution, appeals and efficient follow through on all aspects of the process which has direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care and follow up.

Efficiently handles all administrative details and duties requiring extensive experience with policies, procedures and practices of the University of Rochester Medical Center, Golisano Children's Hospital, and Ambulatory Department.

Serves as an administrative resource for faculty and staff and supports the Practice Assessment Clinic Transformation administrative needs. Demonstrates ICARE* values in each of the major responsibilities.

JOB DUTIES AND RESPONSIBILITIES:

• Prepares and provides multiple, complex details and facts to insurance carrier or worker's compensation carrier to obtain prior authorizations for both standard and complex requests such as invasive procedures and complicated surgeries but also for medication, imaging, non-invasive procedures, sleep studies etc.

• 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.

• Develops and utilizes and modifies tracking mechanisms to ensure all renewals/approvals are obtained

• Primary contact for Pediatric Practice referral functions and triages calls as needed. Maintains reports for referral outcome and process.

• Responsible for all aspects of referral coordination, including obtaining referrals from all sources, electronic medical record, fax, in basket and email

• In processing referrals for Pediatric Practice providers, prioritizes referrals by following and applying standard policies, procedures and practices.

• Responsible for laboratory and imaging follow up and coordination for patients with uncompleted/ overdue labs and images.

• Employs multiple tracking mechanisms to ensure that referral approvals and appointments are obtained in a timely way so that patients are always cleared for their appointment prior to their arrival.

• Develops Pediatric Practice standards and workflows for referrals and prior authorizations.

• Provides monthly referral and prior authorization reports to Administrators and Pediatric Practice Leadership team

• Participates in monthly Primary Care Medical Home (PCMH) meetings and provides quarterly reports to PCMH committee.

• Responsible for laboratory and imaging follow up and coordination for patients with uncompleted/ overdue labs and images.

• Connects patient to appropriate internal departmental staffing to assist with overcoming any identified barriers or social determinants of health.

Other duties as assigned

QUALIFICATIONS:

• High School Diploma and a minimum of two years of relevant experience required, or an equivalent combination of education and experience.

• Medical Terminology, experiences with surgical/appointment scheduling software and electronic medical records, preferred.

• Demonstrated customer relations skills required.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University's mission to Learn, Discover, Heal, Create - and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $18.89 - 25.51 Hourly

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.