Patient Advocate III

Organization:

MPHS-Mills-Peninsula Medical Center

Position Overview:

Responsible for insurance verification and eligibility, assessment of patient financial requirements, counseling patients on insurance benefits and co-payments, and obtaining preauthorization for all services. Works closely with department staff, physicians and practice staff to facilitate timely start and continuity of services. Works in conjunction with managed care and coding departments to maintain accuracy in clinical and billing information.

Job Description:

These Principal Accountabilities, Requirements, and Qualifications are not exhaustive but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

PATIENT ADVOCATE SERVICES:
• Verifies all insurance and eligibility information is accurate and updates insurance records 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 are delivered to patients in a timely manner.
• Review schedules a minimum of 5 days before ensuring all treatments are authorized.
• Associates authorization with patient’s appointment in the scheduling system.
• Accurately enters all authorization requests into the EPIC system utilizing appropriate codes, treatment types, and providers.
• Enters supporting data into the comment box. Communicates with supervisor or charge nurse, physicians, and practice staff when there are authorization issues.


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 the 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 before starting/during treatment regarding insurance benefits and out-of-pocket expenses.
• Provides estimated 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 the appeals process when treatment is denied.
• Meets with pharmaceutical drug reps regarding supported patient assistance programs and refers patients to Social Workers 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:
Equivalent experience will be accepted in lieu of the required degree or diploma.

HS Diploma or equivalent education/experience


TYPICAL EXPERIENCE:

2 years of recent relevant experience.

SKILLS AND KNOWLEDGE:

Knowledge of chemotherapy medications and regimens and other costly injectable medications.

Familiarity with 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.


Pay Range: $35.65 - $44.56

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Friday, Monday, Thursday, Tuesday, Wednesday

Weekend Requirements:

None

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

1

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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