What are the responsibilities and job description for the PreCert/Financial Advocate position at Mysomc?
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Department: Cancer Center Support Services
Shift/schedule: Full Time (40 hrs/wk)
GENERAL SUMMARY
Works under the supervision of the SOMC Cancer and Infusion Support Manager. The PreCert/Financial Advocate primary job functions are to perform insurance verification/benefits investigation/medical necessity to obtain proper pre-certification/pre-determination for medical oncology/infusion services, radiation oncology, internal and external laboratory, molecular and genetic testing among other services. The PreCert/Financial Advocate is also responsible for identifying patients in need of patient assistance programs, obtaining the programs and monitoring the collection and applying collected money to correct patient account. Performs other duties as assigned.
QUALIFICATIONS
Education:
- High School Diploma or successful completion of an equivalent High School Exam Required
- Associates Degree in Business or health related field preferred
- Coding Certification or related experience preferred
Licensure:
- BLS within 90 days of hire required
Experience:
- Six to twelve months of related work or hospital billing/coding experience required.
- Insurance knowledge preferred.
- Medical terminology and medical office, and coding experience required.
- Familiarity with diagnoses and treatments preferred.
- Computer skills (including Excel, Word, Smartsheet, CoverMyMeds, and internet use).
JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS
The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.
1. Verifies insurance benefits, identifies under insured, and obtains proper authorization and certification to ensure timely and proper payment.
2. Review chart documentation and ensure that patients meet medical necessity policy guidelines.
3. Prioritize Authorization Requests:
- Handle incoming authorization requests based on urgency
- Verify the accuracy of CPT and ICD-10 diagnoses in the procedure order.
- Obtain authorization through payer websites or phone calls
- Regularly follow up on pending cases.
- Answer detailed clinical questions.
4. Communicates with providers, entering care plan coverage information, pre-certifications, and changes to the care plan. Respond to clinic inquiries regarding payer medical guidelines.
5. Identifies self-pay patients and communicates with the patient letting them know that he/she will provide assistance to explore payment of prescribed medications from patient assistance programs or replacement programs.
6. Assist patients with HCAPS and documentation.
7. Obtains necessary documents to pursue payment or replacement and submits appropriately. ABNs are collected as required.
8. Meets with and communicates with pharmaceutical field representatives, staying informed of available programs and up to date with enrollment processes.
9. Maintains responsibility for correct payment information in the appropriate systems.
10. Identifies patients for co-pay assistance or free/replacement drugs in the TailorMed software system. Once identified, obtains patient consent and applies for assistance through TailorMed.
11. Keeps updated on changes in insurance policies by reading the Experian Alerts received.
12. Gathers information such as requesting medical records, corrected UB's, EOB's, completing appeal forms and creating appeal letters with explanations for non-technical denials.
13. Understand the impact of procedure authorization on the organization’s revenue cycle.
14. Multitask while managing a high-volume, time-sensitive workload
15. Assists in onboarding and education of employees.
16. Accepts other duties as assigned.
Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position in accordance with applicable law. A full job description is available upon request.
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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.