Patient Financial Advisor

Job Summary:

This position is responsible for determining 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 Patient Financial Advisor completes a financial assessment, requests patient payments, 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. 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 clinics for evaluation and assessment of patients financial situation. Independent decisions are required within the scope of responsibilities including authorization of payment means or sources, which impact sources of 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.

Essential Responsibilities:

• 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 for Emergency, Outpatient, Inpatient encounters prior to, during and post 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.
• 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 for Emergency, Outpatient, Inpatient encounters prior to, during and post 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.
• Identifies commercial, self-pay or under insured account coverages and is responsible for following up with the patient/patients family to request payments, negotiates 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.
• Understands the work processes of Patient Access Representative with abilities to perform such that they are accountable 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 medical services.
• Interviewing patients regarding possible workers compensation coverage, Coordination of Benefits and/or Third-Party Liability.
• 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 sound judgment according to policy.
• Provides patient liability information to and collects from patients based on guidelines and/or systems provided by the department, including but not limited to:
• co-payments
• deductibles
• co-insurance
• deposits
• outstanding prior balances
• Knowledge of medical terminology, diagnostic related groupings (DRGs/MSDRGs), diagnosis code (ICD-9-CM) and common procedure terminology (CPT 4/APC) codes to determine benefits and estimate service cost.
• Knowledge of other pertinent federal and state health care regulations such as HIPAA and EMTALA, CMS, TJC, etc.
• Analyzes patients financial information and provides financial screening advice to patients, when appropriate, regarding payment options and scheduling and location alternatives.
• Assisting patients with understanding their benefits when a cost-share is owed.
• Complete CMS regulatory forms with patient or representative based upon admission status, in partnership with Care Management. (IMM, MOON, 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.
• 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.
• Perform audits to determine the accuracy and completeness of the data collected on the 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.
• Responsible for maintaining records during system downtime and assist in recovery processes.
• 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.
• Accommodates work schedule and shift flexibility according to department needs.
• Contributes to the success of the organization by participating in the organizational and customer service/employee relations action plan programs, keeping current on new developments within the Kaiser Permanente Organization.
• Maintains working knowledge of Fair Debt Collection Laws along with State and Federal rules and regulations for billing Medicaid, Medicare, Champus, etc.
• Performs other duties as needed or assigned.