Referral And Authorization Specialist

Southern Tier Cardiology

Referral and Prior Authorization Specialist,

POSITION SUMMARY: 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. Follows up daily on all pending prior authorizations and insurance referrals for offices.

SUPERVISION AND DIRECTION RECEIVED: Receives minimal direction from physician, mid-level providers, department head and/or administrative assistant or administrator. Is responsible for independently planning, executing and evaluating own work. Works independently with latitude for action.

20% Referral

· Responsible for managing department referrals. Serves as liaison, appointment coordinator, and patient advocate between the referring office and patient to assist in the coordination of scheduled visits and procedures incorporating all incoming referrals to the department using Epic Referral work queues as required. Consistently monitors the work queues and communicates with referring and referred to departments to reconcile any discrepancies and/or answer any questions. 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 as needs assessments using information from the electronic medical record to assure the appropriate appointment/procedure is scheduled 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.

35% Internal Prior Authorizations

· Prior authorization functionality required for testing and services ordered by providers 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., 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 (i.e., medication could not be utilized due to heart condition). 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 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. Uses system tracking mechanisms to ensure all renewals/approvals are obtained prior to patient arrival.

15% External Prior Authorizations

· 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.

30% Other :

· OAS duties- Serves as OAS in Southern Tier offices.

QUALIFICATIONS:

Associate's degree in Medical, Secretarial or related field and a minimum of three years of relevant experience required, or an equivalent combination of education and experience. Demonstrated customer relations skills.

Job Type: Full-time

Pay: $18.50 - $24.71 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Weekly day range:

• Monday to Friday
• No weekends

Work Location: In person