SPEC TRANSPLANT FINANCIAL

Receive 17% weekday nights, 26% weekend nights, or 15% weekend day shift differentials!

Department: Kidney Transplant Svcs
FTE: 1.00
Full Time
Shift: Days

Position Summary:
Serve as the primary point of contact in determining financial clearance, planning and coverage of the pre- and post-transplant patient. Provides accurate and complete data input for Prior-Authorization requests. Review structured clinical data, matching it against specified medical terms and diagnoses or procedure codes (without the need for interpretation). Assess insurance coverage and financial situation for transplantation and post-transplant medication coverage. Determines and obtains authorizations/pre-determinations on all pre-scheduled procedures to secure reimbursement of the case. Communicates with patients to assure payment obligations are understood and steps necessary to meet these obligations are communicated. Assist in resolving transplant patient and living donor issues. Maintain a positive patient experience serving as patient advocate and liaison, interfacing with patients, family, and multi-disciplinary team members including physicians. Ensure adherence to hospitals and departmental policies and procedures. Patient care assignment may include neonate, adolescent, adult, and geriatric age groups.

Detailed responsibilities:
* REFERRAL - Collaborates with multi-disciplinary transplant team members to ensure referrals are in place prior to transplant patient visits, evaluation, surgery and post-transplant care
* COORDINATION - Coordinate with hospital and transplant team, transplant social worker, providers, and other applicable areas in obtaining grants and special assistance funds; provides information to the transplant team about potential compliance or other pertinent issues
* CUSTOMER SERVICE - Acquire prior patient records, patient billing, referral information and lab results
* CUSTOMER SERVICE - Assist referring providers in resolving problems, locate UNM physicians and forward documents
* ELIGIBILITY - Verifies insurance coverage and benefits on patients needing referrals and authorizations for transplant evaluation, wait-listing, transplant surgery and post-transplant care
* PRIOR AUTHORIZATION - Comprehension of insurance data, benefits, in/out of network issues, notification requirements, pre-determination services and medical diagnosis is consistently demonstrated in order to ensure that all prior-authorizations are completed prior to date of service
* PRIOR AUTHORIZATION – Accurate and pertinent clinical data and demographics is compiled and communicated to the patients’ insurance company in a timely and organized fashion. Knowledge of insurance carrier criteria for Surgical, Diagnostic procedure is current. Using independent judgment, employee determines if he/she has sufficient information to meet criteria for Surgical/Diagnostic services. If sufficient information is not provided employee collaborates with clinical staff/physician to ensure criteria is met
* PRIOR AUTHORIZATION - Identify issues, patterns, trends in obtaining authorization from insurance carriers, work with Patient Access Management to implement procedures to improve authorization process and/or to bring forward to Executive Management for their involvement when needed
* KNOWLEDGE - Maintain knowledge of ICD/CPT codes. Assign ICD/CPT codes as required by insurance carriers in order to obtain prior authorization for services
* FINANCIAL COUNSELING – Schedule financial assistance appointments; meet with the patient and their family to discuss financial obligations, calculating co-pays, deductibles and co-insurance and self-pay estimates using tools provided
* DOCUMENTATION - Complete and fax paperwork and pertinent medical documentation to insurance companies and other payors for approval; document final prior authorization in financial systems
* DOCUMENTATION - Document all patient/clinical communications in financial system, transplant clinical database and charting system; prepares for and participates in Transplant Listing Committee meetings in terms of financial clearance of potential transplant candidates
* DENIALS – Track, investigate, correct claims with appropriate authorization information and create appeal letters for payment of denials due to "no authorization"; report detailed information to supervisors and work with billing office representatives to coordinate appeal efforts
* TRAINING - Provide staff training as needed
* PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
* PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
* PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"

Qualifications
Related Education and Experience may be substituted for one another on a year for year basis.

Education:
Essential:
* Associate Degree
* Course
* Training
Nonessential:
* Bachelor's Degree
Education specialization:
Essential:
* Medical Terminology Course w/in Six Months of Position
* Transplant Financial Coordinator Assoc (TFCA) wrkshp w/ 1YR
Nonessential:
* Related Discipline

Experience:
Essential:
2 years directly related experience

Nonessential:
Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo

Credentials:
Essential:
* Not Applicable/Not Required

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment