Referral & Prior Auth Rep III

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.

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; Manages department referrals; Serves as liaison, appointment coordinator, and patient advocate; Conducts data analyses and monitors work queues; Prioritizes referral requests and expedites urgent requests; Acquires insurance authorization and documents communications; Prepares and provides details to insurance or worker's compensation carrier to obtain prior authorizations; Coordinates peer-to-peer reviews for denied services; Manages orders for patients being seen in ED/Urgent Care; Processes outgoing referrals; Processes incoming referrals not generated within the UR system; Performs other duties as assigned

Requirements

High School diploma or equivalent and 2 years of relevant experience required; Or equivalent combination of education and experience; Demonstrated customer relations skills required

Nice to have

Medical Terminology; Experience with surgical/appointment scheduling software; Electronic medical records