What are the responsibilities and job description for the PRIOR AUTHORIZATION AND REFERRAL SPECIALIST (UT Health RGV Cancer and Surgery Center) position at The University of Texas Rio Grande Valley?
Number of Vacancies
1
Location
McAllen, Texas
Department
School of Medicine/ Revenue Cycle
FTE
1.0
FLSA
Non-Exempt
Scope of Job
Responsible for obtaining and processing all diagnostic imaging prior authorizations and referrals and entering the completed referral into the electronic medical record system for claims adjudication to ensure services are validated.
Description of Duties
- Processes diagnostic imaging prior authorizations and referral requests in a timely manner, prior to the patients’ services being rendered.
- Responsible for researching patient member benefits, additional coverages, coverage limitations, and general coverage allowances to obtain the necessary authorizations and referrals for patient services.
- Obtains and receives referral requests from providers and health plans related to services for patient visits and procedures.
- Verifies member eligibility and benefits via the health plan provider online portals or health plan provider eligibility services via fax or phone and enters the information into the EMR system accurately for authorization tracking.
- Notifies the necessary parties within the required timeframe for routine and urgent requests for services.
- Communicates with patients to effectively educate them on any limitations or additional services that may require contact with their insurance carrier to ensure coverage.
- Communicates with providers, physicians, and other medical personnel regarding necessary documentation, CPT codes, diagnoses codes, or other information required to obtain the necessary authorizations or referrals.
- Communicates with patient service representatives to obtain or correct patient demographics as needed.
- Communicates authorization information and coverage to appropriate departmental staff in a timely manner.
- Communicates effectively with health plans, payor representatives, and network and claims department staff to resolve complex authorization issues.
- Coordinates with health plans and payor representatives for outpatient, inpatient, DME discharge planners, home health providers, and other services as needed when applicable.
- Is a source of knowledge for primary care providers regarding specialist referrals.
- Performs other duties as assigned.
Supervision Received
General supervision from assigned supervisor.
Supervision Given
Direct supervision of assigned staff.
Required Education
High School diploma/GED.
Preferred Education
None
Licenses/Certifications
None
Required Experience
One (1) year of experience processing prior authorizations and referrals in a medical setting. Knowledge of interpreting commercial insurance coverages to include: Medicaid and Medicare.
Preferred Experience
Experience processing diagnostic imaging prior authorizations and referrals in a medical setting.
Bilingual, Spanish speaking preferred.
Bilingual, Spanish speaking preferred.
Equipment
Use of standard office equipment including knowledge of Microsoft Office and previous use of EMR (Electronica medical record systems).
Working Conditions
Needs to be able to successfully perform all required duties. Office/Clinic Environment; some travel and weekend work is required. Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. UTRGV is a distributed institution, which requires presence at multiple locations throughout the Rio Grande Valley.
Other
Exceptional computer skills and experience are required. The ability to work independently with minimal supervision and strong organizational skills with attention to detail is necessary to ensure efficient and quality operations. Ability to interpret medical insurance coverages. Strong knowledge of insurance terminology.
Physical Capabilities
None.
Employment Category
Full-Time
Minimum Salary
Commensurate with Experience
Posted Salary
Commensurate with Experience
Position Available Date
06/02/2025
Grant Funded Position
No
If Yes, Provide Grant Expiration Date
Posting Detail Information
EEO Statement
It is the policy of The University of Texas Rio Grande Valley to promote and ensure equal employment opportunities for all individuals without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or protected veteran status. In accordance with the requirements of Title VII of the Civil Rights Act of 1964, the Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, as amended, our University is committed to comply with all government requirements and ensures non-discrimination in its education programs and activities, including employment. We encourage women, minorities and differently abled persons to apply for employment positions of interest.
Special Instructions to Applicants
Dear Applicant, Human Resources will not be held responsible for redacting any confidential information from the documents you attach with your application. The confidential information includes the following: *Date of Birth *Social Security Number *Gender *Ethnicity/Race Please make sure that you omit this information prior to submission. We are advising that Human Resources will be forwarding your application to the department as per your submission. If you have any questions, please do not hesitate to contact us at (956)665-8880 and/or careers@utrgv.edu.
Additional Information
UTRGV is a distributed location institution and working location is subject to change based on need.
All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.
Substitutions to the above requirements must have prior approval from the VP of HR & Talent Development .
All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.
Substitutions to the above requirements must have prior approval from the VP of HR & Talent Development .
