Performs benefit investigation and patient education on applicable assistance programs. Obtains insurance authorizations, review of claim denials with resolution, and acts as a liaison between the patient and Patient Financial Services. Maintains current knowledge of insurance and governmental payer coverage criteria by drug and diagnosis.
Reports to: Cancer Center Director and Assistant Director
Communicates with insurance companies to perform primary benefits investigation to obtain patient eligibility, benefits, copays, and policy restrictions. Meets with each new patient to communicate benefits information and patient financial responsibility in a clear and concise manner.
Educates patients on applicable assistance programs including government programs Medicare and Medicaid, Charity care, drug replacement programs, grant and foundation programs, and community resources. Assists patients in obtaining assistance by completing program forms, collecting financial documentation, submitting forms, and tracking status. Accurately documents all assistance program awards on tracking spreadsheet and EMR.
Monitors patient accounts that have been awarded assistance program funds. Submits claims and primary insurance EOBs to the program for reimbursement of funds due. Receives payments from foundations and documents all payments accurately and timely on tracking spreadsheet. Adds the appropriate agency payer to the patient's accounts, documents the account, and submits all agency payments to the posting department.
Obtains insurance authorizations for chemotherapy, infusions, and injections as ordered by providers. Documents detailed authorization information in the EMR. Attaches the authorization/referral to the appropriate treatment appointment to ensure accurate and timely billing of services. Re-authorizes treatments, as necessary. Monitors work queues daily to obtain timely authorizations and address expiring authorizations. Communicates any denials directly with the provider. Works directly with drug manufacturers as appropriate to obtain free or replacement drug when no available payer source for treatment offered. When free or replacement drugs are obtained, works with pharmacy for crediting the patients account and claim prior to billing to the payer.
Responsible for reviewing claim denials related to authorization and medical necessity in work queue. Works closely with the Business Service Center to perform primary research and insurance contact to resolve denials.
Primary contact for patients to discuss billing and help facilitate discussions with the Business Service Center.
Maintains current knowledge of insurance and governmental payer coverage criteria by drug and diagnosis. Understands and maintains knowledge of NCCN guidelines, FDA regulations, and CMS NCD/LCDs for appropriate coverage and payment for treatments. Communicates directly with the provider and clinic manager as needed to discuss coverage issues and concerns
High school diploma or equivalent required
Certifications: Basic Life Support (BLS) is required through American Heart Association (AHA)
Licenses: Current North Carolina or compact state Registered Nurse license preferred
*Minimum Work Experience*
Registered nurse preferred. Two (2) years of healthcare billing or patient financial experience preferred. Computer skills required, with Microsoft Word and Excel experience preferred.
Oncology experience preferred.
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, federal, state and third-party claims processing requirements, explanation of benefit (EOB) statements from insurance companies and regulations and procedure manuals.
• Ability to complete financial assistance applications.
• Ability to write routine reports and correspondence.
• Ability to speak effectively before groups of customers and coworkers.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to compute rate, ratio, and percent to draw and interpret bar graphs.
• Ability to use hospital financial systems.
• Working knowledge of Word, Excel, and Microsoft Exchange.
• Proficient keyboarding skills.
• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
**Job:** **Please select a valid job field*
**Title:** *Clinical Financial Counselor*
**Requisition ID:** *7460-7338*