The Program Financial Coordinators (PFCs) are part of a multidisciplinary team responsible for providing accurate and professional financial clearance to patients seeking Transplant Services or Chemotherapeutic Services at Duke.
The PFCs are responsible for the analysis, validation, regulatory & compliance activities associated with the financial clearance process for Transplant and Chemo therapy patients.
The PFCs mitigate the financial risk to Duke Medicine and the Private Diagnostic Clinic of Transplant patients and Oncology patients by performing an accurate financial clearance review along with a comprehensive analysis of patient and payor specific benefits and patient liability.
Coordination and communication with the patient, clinical teams including physicians, nurses, social workers and pharmacists is key for the successful financial analysis and clearance.
Work is performed under the direct supervision of the Transplant Financial Services Manager or Financial Services Manager with administrative direction provided by the Administrative Director of Service Access.
Duties and Responsibilities: (100%) 1. Process New Referrals for Evaluation / Insurance Verification/Clinical Coordination Analyze, organize, and utilize complex data and rules related to contracting and patient benefits to provide financial clearance.
Work with DUHS Finance, Managed Care Contracting, Pharmacy assistance programs in the development of agreements for International, self funded patients and patients with limited benefits.
Interact with Transplant / Oncology Clinical teams (Surgeon, Medical Oncologists, RN Coordinators and Transplant Administration) to obtain treatment plans, discharge planning, concurrent and retrospective review and patient demographics to begin insurance verification process.
Interview admitted patients to obtain required information to begin verification.
Interact with Clinical teams (Surgeon, RN Coordinators and Transplant Administration) prior to a patient financial clearance, providing key information and data regarding benefits, support and patient financial liability.
Prepare financial packets based on each individual patient#s benefits, patient financial interview, and calculated estimated expenses based on patient benefits.
Share financial screen daily / weekly with the clinical teams at each of their respective meetings. Notify the patient if not financially approved for evaluation at Duke and redirect these patients to the insurance payer#s case manager Data Maintenance and Billing Information for (Transplant specific) work: Identify the correct patient in Epic. Accurately identify which account is to be used for the visit.
Update demographic and insurance information in Epic and the transplant database when informed of changes.
PFCs perform a review of each patient visit to determine if a visit was transplant related in order for accurate billing to occur.
Communication with the clinicians occurs daily to confirm some visit requirements.
Changes are communicated to the Clinical Team and Administration as necessary.
On-going financial review /analysis review and analyze patient#s eligibility, benefit changes and financial status once a patient is accepted for evaluation and through transplant.
Patients are followed approximately up to one year post transplant by the PFC.
The PFCs are cross trained to provide weekend and evening coverage for solid organ transplant referrals in an effort to provide timely financial feedback to the surgeons.
Patient Identification /Pre-registration Identify the correct patient in Epic & other systems (ie/ Concert).
Accurately identify which account is to be used for the visit.
Update demographic and insurance information in Epic.
Obtain a Duke Medical Record number for new patients.
Analyze benefits for appropriate coverage for services; review contracts and obtain clarification from Managed care Contracting and Payor Coordination as needed.
Resolve Epic system alerts for missing or incorrect registration and insurance elements.
Add / edit insurance per policy and procedure.
Work with clinical staff to obtain additional clinical information for benefit review in particular as it relates to clinical trials and off label drug use.
Interview Patients / Provide Financial Counseling Meet with patients and family members at the time of transplant evaluation or prior to chemotherapeutic treatment.
Assist patients with a financial plan when not adequately funded for transplant (e.g. fundraising) or therapy services # Implement appropriate collection actions and assist financially responsible persons in arranging payment.
Explain billing to patients according to PRMO credit and collection policies.
Notify the Transplant Clinical team of financial considerations that prevent or delay listing the patient for transplant.
Inform the Oncology Clinical team of financial considerations.
seek clinical assistance as needed.
Refer patients to the Manufacturer Drug program and Pharmacy Assistance programs as needed for medications.
Obtaining Authorization and Prior Approval Analyze benefit requirements and initiate the request for authorization / prior approval for the transplant evaluation, admission, clinic visits, donor compatibility, work-up and testing, organ procurement, and follow-up appointments.
Analyze benefit requirements, initiate authorization, pre-certifications and /or pre- determinations for chemotherapy treatments; work with clinical staff to obtain additional clinical information for benefit review in particular as it relates to clinical trials and off label drug use.
Prepare the medical packet (including letter of medical necessity and clinical evaluation) required for obtain prior approval, authorization, or pre-certification. Document authorizations in Epic per policy and procedure.
Review denials for evaluation and/or transplant and initiate the appeal process with the insurance payer working collaboratively with the patient, family, and physician # Work collaboratively with the oncologists for treatment authorization denials and work proactively with the oncologist, drug manufacturer and payor to obtain coverage and prevent post billing authorization denials.
Gathers necessary documentation to support proper handling of inquiries/complaints.
Courtesy and professional conduct is maintained at all times.
Provides timely and effective service to internal customers.
Case Management (Transplant) Set the next review date in the transplant registration screen to trigger the next period financial verification.
Request updates to the effective and termination dates of the transplant approval when expired.
High School Diploma required. Advanced degree preferred.
Three years of healthcare experience with a minimum of one year in insurance verification, authorization, or billing experience required. One year of experience with a transplant or chemotherapy program preferred.
Position may be subject to membership with the Transplant Financial Coordinators Association (for Transplant team)and may be subject to certification with TFCA.