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The major challenge to this position is to professionally and diplomatically work with and communicate positively with patients of all ages, their families and physicians regarding financial matters and ensures system documentation reflects the correct billing information. i.e., demographic, employer, insurance and that the patient is informed about and understands their financial responsibility.
This position must be able to work cooperatively and professionally with hospital staff, community/outside agencies, and physician offices. Must be able to make independent decisions except in matters involving non-routine problems, requests for sick leave, vacation time, overtime, and assignments for duty.
This position demonstrates high standards of courtesy, performance, documentation, diplomacy and respect for confidentiality.
Will perform a variety of functions and responsibilities related to patient insurance verification and processing from pre transplant to post transplant, to include:
• Advocates for patients and family members and acts as a liaison with insurance companies to assist in obtaining insurance information.
• Obtains detailed benefit information for all aspects of the transplant process from pre transplant through post-transplant care.
• Researches and documents all insurance plans and confirm patients benefit eligibility, including patient liabilities, clauses, riders, and secondary payors.
• Determines primary and/or other insurance eligibility compliance standards based on predetermined regulations.
• Ability to review, analyze and act upon third party benefit discrepancies prior to billing.
• Resolves any discrepancies by contacting appropriate patients, family members, employers, etc. as required.
• Advises patients and family members with regards to next steps or processes for securing financial coverage.
• Assists in locating resources and/or assistance programs for which uninsured/underinsured patients may be eligible.
• Provides information to the appropriate billing specialist to ensure accurate billing for current and future services.
• Reviews and interprets insurance group pre-certification requirements. Ensures proper pre-authorizations have been obtained. Completes any necessary on-line operations for specific payors to complete the pre-certification process. As necessary communicates data to utilization management to continue medical review process.
• Coordinates the ongoing pre-certification and approval process with insurance case managers and assist case managers with discharge planning to coordinate the most appropriate level of care for patients.
• Monitors and updates patient insurance information.
• As required obtains referral from patients PCP prior to admission for managed care plans.
• Determines the extent of liability for insurance plans, coordinates benefit and identifies personal responsibility.
• Manages all transplant related insurance questions and when necessary, obtains information from various sources including but not limited to clinics, physicians, patients, attorneys, employers, payors, and other outside agencies.
• Communicates financial information and payor requirements to the transplant team.
• Ability to identify and print necessary medical documents and forward to payors.
• Together with the Director of Managed Care Contracting participate in negotiating one-time single case agreements, including contractual provisions and rates with payors and coordinate implementation.
• Maintain a log of single case agreements.
• Maintain up to date records on a daily, weekly, and monthly basis of all accounts pending verification reviews, utilizing transplant database lists and take appropriate action to resolve accounts.
• Represent Renown Health to external agencies on issues involving transplant admissions, financial policies, and procedures.
• Maintain up to date knowledge base of the changes within the insurance industry and analyze/update patient accounts according to current guidelines and standards.
• Completes notification and evaluation results form for commercial on-line systems in a timely manner to assure payment.
• Functions as transplant programs primary resource for patients that have questions related to insurance coverage and related financial matters.
• Facilitate resolution of patient billing issues related to transplant.
• In conjunction with the social worker acts as a liaison with pharmaceutical companies regarding patient prescription drug coverage and coordinates applications for coverage on the patient’s behalf, as necessary.
• Performs payment verification on all transplant cases.
• Attends weekly transplant team meetings to provide patient specific information.
• Accurately maintains required departmental statistical data.
This position does not provide patient care.
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