Under general direction of Manager/or Team Leader, the Financial Clearance Counselor ensures that patient demographic and financial information is complete in the hospital’s registration and billing systems by working directly with Patient, Admitting Physician’s Office, Patient Accounts and third-party payers. Determines eligibility and obtains authorizations from third party payers for all types of admissions/procedures (i.e. Surgical Day Care, Inpatient, Bedded Outpatients, Outpatient Diagnostic Services). Clinical Review of patient medical history is required to determine services patient expected to receive and to complete payer and third party authorization requests for these services Acts as a liaison among patients, admitting physician offices, case management, and third-party payers ensuring that all third-party payers’ requirements are met. Divisional goal is to maximize reimbursement while serving the needs of our internal and external customers. All staff members are expected to complete any additional tasks as assigned by Manager.
Financial Counselors are responsible for in-depth evaluation of financial history for both uninsured and underinsured patients for the purpose of determining eligibility for government and financial assistance programs. Serves as the primary contact when patients require assistance with various billing/financial related issues. Will have strong working knowledge of all aspects of the revenue cycle including Financial Clearance, billing related questions and the charity care process. Utilize a variety of available resources and contacts to assess and work towards the resolution of identified patient fiscal issues. Financial Counselor will provide onsite educational and informational counseling to patients and families to help them understand the financial aspects of their care including; insurance coverage/requirements related to their treatment plan, care estimates and potential out of pocket expenses, assistance completing financial assistance program application and referral to applicable agency for assistance applying for government programs.

1. Utilizes organizational, clerical skills and computer applications to acquire and maintain knowledge and competency in Financial Clearance/Financial Assistance and Revenue Cycle to ensure process efficiency.
a. Understands and stays current with knowledge of insurance contracts and payer policies related to financial clearance/financial assistance and authorization.
b. Maintains work area in a professional manner. Troubleshoots department equipment. Notifies department manager or supervisor or IS of unresolved failures.
Maintains filling systems according to department standards.
c. Efficiently utilizes and maintains the knowledge pertinent to the various computer applications and systems within the department.
d. Participates in ongoing educational activities related to Financial Clearance/Financial Assistance.
e. Acquires and maintains knowledge and competency in all areas of Financial Clearance/Financial Assistance, including but not limited to Order Control, Pre-certification, Pre-Registration, Scheduling, Eligibility Worklists and Financial Assistance.
f. Seeks constructive feedback regarding his or her own work in the revenue cycle. Makes changes base on feedback provided.

2. Demonstrates a high level of professionalism through active participation in team initiatives.
. Requires minimal direct supervision, functions well within the team and fosters the team initiatives.
a. Serves as a department liaison in the absence of the Manager/Supervisor/Lead.
b. Plans and performs additional functions within the team assignments and department as directed.
c. Participates in the orientation and education of internal personnel. Assists in the maintenance of all pertinent training materials, sign off sheets and public education resources.
d. Assists in the prep of agendas for team meetings and completing of meeting minutes.
e. Works in conjunction with leadership and peers to maintain staff coverage for planned and unplanned time off.
f. Maintains and utilizes a distribution list for internal and external education relevant to Financial Clearance/Financial Assistance.

3. Expertly completes all tasks related to order control, insurance verification, financial assistance and pre-certification processes in accordance with organization standards and State / Federal government regulations.
. Validates orders based on RC-09 requirements, along with department protocols. Works in conjunction with Physician Practices and Ancillary Departments to obtain valid orders.
a. Ensures ICD Diagnostic codes and CPT Procedure codes are appropriate for the ordered procedure and meet medical necessity / medical policy and are accurately used to obtain authorization.
b. Confirms insurance eligibility and coverage of benefits for the ordered procedure(s) and documents insurance status in the system prior to the patient receiving services. Informs appropriate parties of any discrepancies.
c. Verifies that authorizations submitted by outside ordering facilities are approved and are for the correct date of service or coverage dates / facility / ordering provider / procedure / ICD and CPT code(s).
d. Obtains authorizations for required outpatient diagnostics ordered by WDHS Providers in a timely manner and document authorization determination in the appropriate system. Communicates discrepancies with appropriate parties and completes all required follow ups.
e. Informs patient and admitting physician of any potential problems prior to admission/procedure.
f. Determines and informs patient of potential liability prior to admission. Appropriately refers patients to and works as a team unit with Patient Financial Services for counseling if patient is unable to meet financial obligation. Collaborates with physicians and staff to coordinate rescheduling of patients until reimbursement can be guaranteed.
g. Maintain Epic Workques meeting productivity expectations and schedule out 2 weeks.
h. Maintains the Reference Guides for Precertification and ensures that it is updated/shared in a timely fashion after each update. Conducts reviews of the payer websites to ensure accuracy and documents revisions.
i. Utilizes price estimation software to produce out of pocket estimates for patients.
j. Works in conjunction with leadership to research and/or appeal denials related to authorization. Assist with implementation of necessary workflow changes and education materials in response to denials and to mitigate future denials.
k. Communicates with payers and Case Management to ensure notification and clinical requirements for all bedded patients are submitted timely. Obtains notification or authorization accordingly and enters determination into system.

4. Understands and can clearly communicate the Patient Financial Responsibility Agreement and corresponding Policy to both internal and external customers.
. Leads financial counseling conversations and offers education to patients about insurance, coverage of benefits, authorization and out of pocket responsibilities. Appropriately documents conversations in system. Completes follow up conversations and action items as needed.
a. Properly utilizes the Patient Financial Responsibility Agreement. Respectfully completes discussion with the patient or representative and documents the form accordingly. Informs department of expected patient decision for service and offers support at the time of patient's check in.
b. Maintains knowledge of and ability to assist with support services that are available to patients, including but not limited to; payment plans, financial assistance and financial planning. Understands and can clearly explain the Financial Assistance Policy and the eligibility criteria.
c. Troubleshoots patient financial responsibility concerns. Reviews occurrences with leadership and documents appropriately. Responds to patient inquiries in a timely manner.
d. Assists with maintenance of the Patient Financial Responsibility Agreement and related policy, and all pertinent forms and education materials.

5. Demonstrates competence in the performance of duties and responsibilities related to State benefits
. Maintains knowledge of various state programs and the criteria to meet eligibility for these programs.
a. Refers patients to applicable agency to apply for state or federal benefits.
b. Obtains a signed release for all perspective and/or active Medicaid patients if needing to follow up with the Department of Health & Human Services on application status or benefit verification.
c. Timely documentation in all Patient Accounting System.

6. Demonstrates competence in the performance of duties and responsibilities related to Financial Assistance program.
. Stays abreast of current Financial Assistance Policy.
a. Guides/assists patients with Financial Assistance application process and submits applications for review/determination immediately upon completion.
b. Ability to maintain a rapport with affiliated providers who provide services to patients and honor our Financial Assistance.
c. Maintain and update training/reference guides.

7. Provides onsite educational and informational counseling to patients and families to help them understand the financial aspects of their care.
. Review with patients their insurance coverage/requirements related to their treatment plan.
a. Obtain and review care estimates and potential out of pocket expenses with patients.
b. Maintains CMS Certified Application Counselor (CAC training/credentialing to assist with ACA/Marketplace questions or enrollment.

Experience Minimum Required

• Minimum of 3 years of experience working in a healthcare clerical or insurance related field, or an associate's degree, or active pursuit of a bachelor's degree.
• Demonstrates team concepts, the ability to multitask, lead and communicate effectively.
• Financial Counseling/Customer Service

Experience Preferred/Desired

• Previous experience in the healthcare insurance field, preferably in a hospital setting.
• Experience with financial counseling, reimbursement and collections in a healthcare setting.
• Knowledge of current computer systems and software applications

Education Minimum Required

• High School Diploma or GED.
• Successful completion of a Medical terminology course.

Education Preferred/Desired

• Two- or four-year College Degree/Associates or Bachelor's Degree in a financial / medical / business field of study

Special Skills Minimum Required

• The ability to multi-task in a fast-paced environment.
• Present in a calm, professional manner.
• Detail oriented.
• Requires the knowledge and ability to utilize various computer and on-line applications.
• Offer exemplary internal and external customer relations.
• Strong relationship building skills and effective communication skills.
• Effective organizational and problem-solving skills.
• Advanced knowledge of medical terminology, insurance verification and authorization processes as it relates to Revenue Cycle.
• HIPPA Privacy guidelines.

Special Skills Preferred/Desired

• Extensive knowledge of insurance coverage, payer policies and authorization requirements
• Prior billing experience
• Certified Applications Counselor (CAC)

WDH Broadway

121 Broadway

Dover 03820