Prior Authorization Specialist

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):

135 Corporate Woods, Suite 200C, Rochester, New York, United States of America, 14623

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500912 Primary Care Administration

Work Shift:

UR - Day (United States of America)

Range:

UR URC 205 H

Compensation Range:

$19.62 - $26.49

Responsibilities:

Oversees data and ensures compliance to enterprise standards and referral and prior authorization guidelines. Communicates regularly with patients, clinical and non-clinical staff, identifying barriers insurance company barriers and tracking all assistance provided. Plans and executes, appeals and follows through on all aspects of the process which has direct, multifaceted impact on patient scheduling, treatment, care and follow up. Reviews reporting for incomplete lab and imaging orders and following protocols outreaches to patients and ancillary departments to ensure patient compliance with timely testing. Adheres to approved protocols for working referrals and prior authorizations.

ESSENTIAL FUNCTIONS

• Serves as point of contact to answer questions and solve problems for difficult and unusual authorizations.  Assists in problem identification, quantification, and resolution.
• Prepares and provides multiple, complex details to insurance carriers to obtain prior authorizations for both standard and complex requests, such as imaging, medications, and 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 general medical experience and terminology, 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. 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.
• Utilizing standard Epic reporting, reviews patient charts, and as necessary, outreaches to patients to ensure completion of all provider ordered testing
• Working proactively with standard Epic reporting of office generated specialist referrals, utilizes payer platform to obtain a health care plan referral for necessary specialty care
• Other duties as assigned

MINIMUM EDUCATION & EXPERIENCE

• High School diploma or equivalent required
• Minimum of 2 years of relevant experience required;
• Or an equivalent combination of education and experience required.

KNOWLEDGE, SKILLS AND ABILITIES

• Medical terminology, EMR experience, Epic preferred; demonstrated customer service skills

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.