Prior Authorization/Financial Analyst II

About this Job: General Summary of Position
Evaluates financial status insurance/compensation coverage and resources of Bone Marrow and Stem Cell Transplant candidates and patients. Assists in insurance pre-authorization process for transplant services. Serves as a key resource in assuring the maximum reimbursement to the institution for required services and in assisting BMT patients to obtain resources to assure the standard of care necessary to maximize transplant success. Coordinates opportunities for reduction of costs and makes recommendations for continuous quality improvement initiatives These functions are performed in accordance with Georgetown University Hospital's (GUH) philosophy policies procedures and standards.

Primary Duties and Responsibilities

• In conjunction with medical staff develops letters of necessity cost/benefit analysis and information requirements of third party payors to help assure maximum consideration for reimbursement. Participates actively in education and outreach programs to insurance companies to affect positive responses to requests for reimbursement.
• Verifies insurance benefits and compensation charges by contacting insurance companies and employers to determine necessity for advance deposits co-payments and deductibles.
• Identifies payor needs and information deficits and coordinates the provision of information to facilitate reimbursement. Performs insurance verification process on all third party payers. Obtains initial and subsequent pre-authorization for services and surgeries.
• Re- verifies benefits and obtains authorization and/ or referral after treatment plan has been established.
• Interviews candidates to determine their insurance coverage and potential eligibility for insurances/programs to expedite payment for Bone Marrow Transplant Services; ensures the completion of appropriate documents to assist in obtaining reimbursement.
• Provide a treatment plan overview of covered and non-covered services as it relates to the patients insurance coverage and /or self-pay responsibility.
• Maintains financial references including: guidelines for reimbursement state and federal regulations payor-specific reimbursement policies.
• Establishes and maintains regular contacts with agencies offering financial aid; develops efficient processes/procedure for candidates to follow to complete the application process
• Adhering to GPG GUH and departmental policies and procedures will access patient Medical Records / Electronic Health Records (MR/EHR) for work related activities only to complete proper patient documentation in the health record or to view needed information in the patient chart as necessitated by job role or function. Adheres to most current work flows or processes developed within GPG or department.
• Assists in the supervision of the Scheduler Front Desk Administrative Support and Department Pre-certification / Authorization staff utilization of MR / EHR ensuring protocols are followed. Monitors staff phone notes prescription requests and other EHR updates for timeliness and appropriateness.
• Maintains continuous contact with MGUH departments (e.g. Admitting Utilization Review Social Work Managed Care Patient Financial Services and Contracting) to assure that the proper pre-admission and pre- certification requirements are followed.
• Assists patients with inquiries regarding financial/insurance issues through data collection assessment and follow-up activities. Identifies appropriate resources to handle problems and complaints effectively. Prepares and presents individualized financial packets for candidates and explains all aspects to candidates so that it is understandable.
• Updates and maintains the respective file/record throughout the patient's involvement with MGUH. Utilizes the Summary of Patient Reimbursement and Liability form and obtains appropriate approvals as required.
• Coordinates the referral pre-certification and authorization process for department including staff adherence to all GPG GUH and Managed Care Department requirements and contracts to ensure all patient appointments/treatments and contracts to ensure all patient appointments have required approvals in advance of the appointment.
• Performs other duties and responsibilities that are appropriate to the position and area.
• The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all inclusive.
• Minimal Qualifications
  Education
  • Associate's degree required or
  • Bachelor's degree a Baccalaureate degree in Health Services Administration Finance or healthcare related field preferred
  Experience
  • 3-4 years Work experience in patient billing and/or insurance claim verification required
  • 1-2 years Experience with claims processing/reimbursement utilization review or case management preferred
  Licenses and Certifications
  • Certified as a Transplant Financial Coordinator preferred obtain this certification within one year of hire. within 1 Year preferred
  Knowledge Skills and Abilities
  • Excellent interpersonal & communication skills;
  • high level of competence in customer relations in a professional environment;
  • ability to prioritize organize work and be self-directed;
  • ability to work as a member of a team;
  • able to work in stressful situations; good problem-solving skills
  This position has a hiring range of : USD $59,820.00 - USD $101,836.00 /Yr.