Regional Patient Financial Advisor NW Foundation Hospitals

Job Summary:

The position is responsible for determining non-KP coverages for patient financial liability and completing the financial assessment, assisting in the discovery of the patient income and assets and in identifying the potential appropriate funding source. This position requires interpretation of information relating to regulatory and statutory requirements, ability to adjudicate insurance benefits and coverage, and interpret viability of financial assistance programs. The role of this position is to support the work at the designated home location with the ability to assist with work assigned at both Kaiser Permanente NW Plan Hospitals. The Patient Financial Advisor completes a financial assessment, requests patient deposits for payment arrangements and makes appropriate referrals to other designated financial assistance vendors. The designated vendors may include Medicaid eligibility processing, Worker Compensation and Third-Party Liability, self-pay assistance, or other community resources. This position determines patients ability to pay based on an assessment of assets and liabilities and negotiates payment arrangements and/or qualification for financial assistance.

This is an expert level position working under minimal supervision. This position requires an understanding and sensitivity to confidential patient and family financial situations and special individual needs at time of service within the hospitals. The Patient Financial Advisor is a liaison with Patient Financial Services and the clinical teams including Social Workers (internal and external), Care Management and Community Services Offices and other local agencies. In doing so, this position will ensure maximum cash flow and reimbursement for Kaiser Permanente NW Foundation Hospitals and acts as a facilitator in resolving patient liability issues. This position will respond to direct requests from clinicians for evaluation and assessment of patients financial situation. Independent decisions are required within the scope of responsibilities including authorization of payment means from payors or other sources, which impact revenue. Major monetary decisions are subject to review and approval beyond predetermined limits.

This position requires the following: 1) Ability to ensure accurate coverages added to the patient account in a timely manner, 2) Accurate and timely assessment of payer and patient liability; 3) Compliance with federal, state, and local regulations; 4) Effective communication with patients regarding personal payment liabilities and options for meeting those obligations. The PFA must create a positive customer experience for all patients through personalized care.

Percent of time for essential responsibilities represents a daily requirement of work duties.

Essential Responsibilities:

• Principle Accountabilities:
• Reviews patient information provided by referring party and/or meets with patient/family member to complete all insurance and financial records or refers if there is a vendor designated to perform these responsibilities.
• Validates eligibility and benefits from insurance carriers at time of service, (emergency, outpatient, inpatient) hospital encounters prior to admission from the emergency room, during and post hospital services, including, continued monitoring for eligibility, authorization of insurance and medical coverage on active patient accounts.
• Gathering and analyzing all patient information pertaining to financial resources and circumstances; and provides financial screening advice to patients, when appropriate, regarding payment options such as Medical Financial Assistance (MFA) application, Medicaid assessment.
• Identifies commercial, self-pay or under insured account coverages and is responsible for following up with the patient/patients family to request payor sources, negotiate payment plans and, if necessary, to assure a Medicaid or financial assistance application is initiated.
• Notifies insurance carriers of intent to admit and initiates authorization for payment of stay.
• Advising and educating patients of their financial care responsibilities, related to current services, including coverage changes, level of care changes, and providing explanation of changes and self-pay financial statements to patients staying beyond medical necessity.
• Understands the work processes of Patient Access Representative with abilities to perform, work alongside the registration team to obtain required demographics to ensure complete and accurate patient admissions/registrations, according to organization policy and procedures and regulatory requirements.
• Identifies, receives internal referrals for or requests from patients who may be at financial risk and/or require assistance to assure payment for current, pending, or prior, and past hospital services to the Financial Counselor team.
• Interviewing patients regarding possible workers compensation coverage, Coordination of Benefits and/or Third-Party Liability, in order to approve coverage.
• Determines patients ability to pay based on an assessment of assets and liabilities and negotiates and approves payment arrangements based on patients financial status and counselors established practice according to policy.
• Provides patient liability information to and collects from patients based on guidelines and/or systems provided by the department, regarding payment arrangement deposits, changes to coverage status.
• Knowledge of medical terminology, diagnostic related groupings /Medicare severity diagnostic related groups (DRGs/MSDRGs), International Classification of Diseases, X Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology/ Ambulatory Payment Classifications (CPT 4/APC) to determine benefits and estimate service cost.
• Knowledge of other pertinent federal and state health care regulations such as Health Insurance Portability Accountability Act (HIPAA) and Emergency Medical Treatment and Labor Act (EMTALA), Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), etc.
• Assisting patients with understanding their benefits when a cost-share is owed.
• Complete CMS regulatory discussions with patient or representative based upon admission status change, in partnership with Care Management. (Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Condition Code 44).
• Inform and delivery of bill summary when financial class changes from a covered payor to a self-pay status. Including explanation of financial obligation going forward throughout the stay, CMS required letters, associated with the level of care change.
• Determines need to consult with Care Management personnel and physicians regarding status of patient admission/and insurance requirements and collaborates as needed.
• Collaborates with Patient Financial Services, Health Information Management, and Clinical Information Systems for regional requirements of patient information, service outcomes, and status of accounts.
• Assists financial assistance vendors/department, when in compliance with the vendor contract, to assure completion of any paperwork that is necessary to obtain payment from appropriate payors, workers compensation case or third-party liability, or works directly with the patient to assist, if there is not a designated vendor.
• Follows-up with patient to resolve any difficulties, completing required paperwork, as appropriate.
• Researches and resolves complex problem accounts at the time of service. Patients may require intensive follow up with resolution prior to discharge.
• Documents all activity pertaining to patients account in the Kaiser Permanente EMR (Electronic Medical Record) system of record (KP HealthConnect).
• Reviews and follow up on electronic reports for incomplete accounts, ensuring all required data fields for insurance verification, reporting and claims submission are accurately completed, to ensure a clean bill.
• Ensures patient information and contact is handled confidentially and the patient is treated with dignity, regardless of financial circumstances patient account at time of service.
• Collecting statistical data and prepare reports, as needed, for success of coverages, authorizations and notifications obtained, including appeal and denials overturned at time of service.
• Performing all or part of duties and responsibilities at the direction of department management based on appropriate needs of the department, and all other tasks and duties as assigned by supervisor.
• The Patient Financial Advisor works collaboratively with Hospital, Clinic, Emergency Department and Member Services personnel to create a customer friendly environment.
• Provides coverage verification support for either facility to meet patient needs from primary location.
• Contributes to the success of the organization by participating in the organizational and customer service/employee relations action plan programs.
• Maintains working knowledge of Fair Debt Collection Laws along with State and Federal rules and regulations for billing Medicaid, Medicare, Champus, etc.
• Corporate Compliance Accountability:
• Consistently demonstrates the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other.
• Work environment will:
• Complete audits to determine the accuracy and completeness of the data collected on the patient account to ensure efficiency of obtaining accurate coverage, eligibility, and authorization.
• Responsible for maintaining records during system downtime and assist in recovery processes, to document all coverages, notifications, authorizations on each patient account once systems are up.
• General Services:
• Performs other duties as needed or assigned.
• Supervisory Responsibilities:
• This position has no supervisory responsibilities.
• Budget Responsibility:
• This position has no budgetary responsibilities.
• Freedom to Act:
• Acts independently to provide answers to benefits questions and concerns.
• Limited supervision and discretion for complex questions or problems.
• Ability to continuously organize and prioritize position functions to accomplish job while working with interruptions and time constraints.
• Collects Point of Service payments of any dollar threshold, for successful payment arrangements.
• Follows role competencies to remain current and compliant, meeting set productivity standards as defined on a case load basis with organizational requirements.
• Interprets medical information to ensure certification and authorization needs are met, at time of service.
• Ascertains accuracy, identifies, and resolves discrepancies and/or corrects errors on demographic and insurance information found in accounts to assist with patient throughput.
• Customer Focused Service
• Connects with members and staff in a caring, respectful manner.
• Actively listens to ensure correct message is heard.
• Shows empathy and sensitivity to members and staffs experiences.
• Handles difficult encounters and/or service breakdowns by minimizing emotions and accommodating members/customers.
• Uses appropriate coping skills in order to maintain positive attitude.
• Responds effectively to help or serve others and meet needs.
• Compliance Responsibility
• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.
• Labor Management Partnership
• For Managers and Supervisors (of employees represented by a Partnership Union): Actively forms Partnerships with Union designated Shop Stewards and other Union representatives; seeks to integrate Union selected staff into relevant decision-making processes.
• For All Employees
• Actively supports the tenets of the Labor Management Partnership.