Organization:
SEBMF-East Bay Medical Foundation

Position Overview:
Responsible for insurance verification and eligibility, assessment of insurance contract status, any applicable managed care requirements, and to obtain timely prior authorization for all services scheduled within the center.

Communicates with Financial Navigator to ensure patient notification of insurance eligibility or contract barriers that will impact cost burden for care and treatment.

Works closely with all administrative clerical staff, physicians and clinical practice staff to facilitate timely authorization requests for continuity of services.

Works in conjunction with managed care and coding departments to maintain accuracy in clinical and billing information.

Job Description:

AUTHORIZATION COORDINATION SERVICES:
• Verifies all insurance and eligibility information is accurate and update insurance record if necessary.
• Responsible for obtaining initial and subsequent Preferred provider organization (PPO) authorizations.
• Initiates referrals to managed care for Health maintenance organization (HMO) authorizations.
• Follows-up to ensure medications delivered to patient in a timely manner.
• Reviews schedule a minimum of 5 days prior to ensure all treatments are authorized.
• Associates authorization with patient's appointment in scheduling system.
• Accurately enters all authorization requests into the EPIC system utilizing appropriate codes, treatment types and providers.
• Enters supporting data into comment box. Communicates with supervisor or charge nurse, physicians, practice staff when there are issues with authorization.

ONCOLOGY:
• May verify chemotherapy and/or non-chemotherapy are Food and Drug Administration (FDA) or compendia approved for given diagnosis as well as meets insurance specific guidelines.
• May perform clinical trial insurance verification and authorization.
• Obtains authorization.
• May submit authorization with prescription to insurance-specific mail-order specialty pharmacies when appropriate.
• Reviews all chemotherapy fee tickets in oncology Electronic Medical Record (EMR) daily or within 48-hours to verify for accuracy of International Classification of Diseases (ICD-9), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) codes and edits as needed. If coding errors and trends are found, is responsible for educating nurses/MDs on correct use of the codes per government payor guidelines. Sends to data processing for posting.
• Follows up in oncology EMR to ensure charges have been posted.
• Provides financial counseling for patients prior to start/during treatment regarding insurance benefits and out of pocket expenses.
• Provides estimate cost of treatment when requested by patient or staff. If an ordered treatment is considered off label per guidelines, the position is responsible for creating and explaining financial/ABN waivers to patients prior to receiving treatment.
• Assists patients who cannot afford meds, treatment or co-pays to access patient assistance programs.

CONTINUOUS IMPROVEMENT:
• Follows the commitment to excellence and treats patients, families, visitors and each other with courtesy, dignity, respect and professionalism.

RELATIONSHIP MANAGEMENT:
• Assists physicians and patients with appeals process when treatment is denied.
• Meets with pharmaceutical drug reps regarding supported patient assistance programs and refers patients to Social Worker for other assistance programs and community services.
• Develops relationships with staff within and outside of the department to facilitate the authorization process and resolution of billing issues.
• Communicates positively and effectively with physicians, staff and patients.
• Works closely with Revenue Cycle to resolve billing issues.

EDUCATION:

HS Diploma or General Education Diploma (GED)

TYPICAL EXPERIENCE:

2 years of recent relevant experience.

SKILLS AND KNOWLEDGE:

Knowledge of chemotherapy medications, regimens, radiation treatment courses and other costly injectable medications.

Familiarity of medical terminology/anatomy.

Verbal and written communication skills for regular contact with physicians, employees, patients and insurance personnel.

Basic high school math aptitude.

Organizational skills.

Ability to work with others in a flexible, cooperative manner.

Computer data entry skills to enter patient and authorization information.

Job Shift:
Days

Schedule:
Full Time

Shift Hours:
8

Days of the Week:
Monday - Friday

Weekend Requirements:
Occasionally

Benefits:
Yes

Unions:
No

Position Status:
Non-Exempt

Weekly Hours:
40

Employee Status:
Regular

Pay Range is $38.20 to $53.48 / hour

The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate's experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health's comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.