Referral & Prior Authorization Specialist III

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):

2337 Clinton Ave S, Brighton, New York, United States of America, 14618

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

400099 SMH Neurology Sleep Center

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:

Serves as the patient referral specialist, with oversight of data and compliance to enterprise standards and referral 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 direct, multifaceted impact (quality, financial, patient satisfaction, etc.) on patient scheduling, treatment, care and follow up. Adheres to approved protocols for working referrals. 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.
• 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.
• Serves as backup to the PSS scheduling team when short staffed, vacations, etc.
• Processes outgoing referrals. Discusses with patient options for outside URMC options for care. Assures Meaningful Use requirements are met. Ensures that 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, additional steps will be taken 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 Epic 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

• Demonstrated customer relations skills required

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture 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 characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.