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Posted: 05-Feb-25
Location: Durham, North Carolina
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Internal Number: 254141
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke Health's Patient Revenue Management Organization
Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions.
The Transplant Financial Coordinator (TFC ) is part of a multidisciplinary team charged with the responsibility of providing accurate and professional financial clearance to patients seeking Transplant Services at Duke. The TFC is responsible for verifying accurate demographic and financial information and knowledgeable in the review and interpretation of insurance benefits, performs financial counseling, and financial screening. Establish financial arrangements, refers appropriate cases to other agencies, internal and external, to assist patients with discharge/post hospital care. Interacts closely with Utilization Review and Transplant Billing to ensure correct and timely reimbursement.
In this role you will coordinate administrative services and operations for transplant financial services. Coordination and communication with the patient and clinical team including physicians, nurses, social workers and pharmacists is key for the successful financial analysis and clearance. Attend weekly and monthly required meetings, maintain transplant work queue's, and all other tasks and administrative duties as assigned.
The Transplant Financial Coordinator has a hybrid schedule Monday through Friday 8:00 am to 4:30 pm as well as being part of the Transplant On-call team when scheduled, which includes working after hours remotely Monday through Friday 4:30pm - 8:00am, holidays and rotating weekends
Work is performed under the direct supervision of the Transplant Financial Services Supervisor and/or Financial Services Manager with administrative direction provided by the Financial Services Director
Primary Duties and Responsibilities
Process referrals for transplant evaluation/Insurance Verification/Clininal Coordination:
- Detailed patient insurance benef it information for aspects of the transplant process including but not limited to outpatient prescriptions, travel and lodging, studies, and fundraising
- Review benefits and other transplant financial issues with patients/family members during transplant evaluation.
- Obtain payer authorizations for transplant evaluation and surgical/waitlist
- Coordinate communication between insurance companies, governmental agencies, providers and internal departments
- Work with DUHS Finance, Managed Care Contracting, Pharmacy assistance programs in the development of agreements for International, self-funded patients and patients with limited benefits
- Interact with Transplant and Oncology Clinical teams (Surgeon, Medical Oncologists, RN Coordinators and Transplant Administration) to obtain treatment plans, discharge planning, concurrent and retrospective review and patient demographics to begin insurance verifiation process
- Interview admitted patients to obtain required information to begin verification
- Interact with clinical teams (Surgeon, RN Coor dinators and Administration) prior to a patient's financial clearance, providing key information and data regarding benefits, support and patient financial liability
- Prepare financial packets based on each individual patient's benefits, patient financial interview, and calculated estimated expenses based on patient benefits
- Share financial screen daily/weekly with the clinical teams at each of their respective meetings
- Notify the patient if not financially approved for evaluation at Duke and redirect these patients to the insurance payer case manager.
Data Maintenance and Billing Information (Transplant specific):
- Facilitate resolution of transplant patient billing issues
- Utilize clinical and billing knowledge to recognize and resolve billing errors/inconsistencies
- Understand federal and state guidelines related to organ transplant
- Identify patient in Maestro and accurately identify which guarantor account is to be used for the visit
- Update demographic and insurance information in Maestro and the transplant database when informed of changes
- Perform a review of each patient visit to determine if a visit was transplant related in order for accurate billing to occur
- Communication with the clinicians occurs daily to confirm some visit requirements
- On-going financial review /analysis, review and analyze patients eligibility, benefit changes and financial status once a patient is accepted for evaluation and through transplant
- Patients are followed approximately up to one year post transplant by the TPFC
- Provide weekend and evening coverage for solid organ transplant referrals in an effort to provide timely financial feedback to the surgeons.
Patient Identification / Pre-registration:
- Update demographic and insurance information in Maestro Care
- Obtain a Duke Medical Record number for new patients
- Analyze benefits for appropriate coverage for services, review contracts and obtain clarification from Managed Care Contracting and Payor Coordination as needed
- Resolve Maestro Care alerts for missing or incorrect registration and insurance elements
- Add / edit insurance per policy and procedure
- Clear TES edits and Hold bills
- Obtain authorizations and pre-certifications as required
- Work with clinical staff to obtain additional clinical information for benefit review in particular as it relates to clinical trials and off label drug use.
Interview Patients / Provide Financial Counseling:
- Meet with patients and family members at the time of transplant evaluation or prior to chemotherapeutic treatment
- Inform patients of the anticipated costs of transplant/chemotherapeutic services, the anticipated patient liability, and the patient responsibilities (e.g. post-transplant medications)
- Assist patients with a financial plan when not adequately funded for transplant (e.g. fundraising) or therapy services
- Implement appropriate collection actions and assist financially responsible persons in arranging payment
- Explain billing to patients according to PRMO credit and collection policies
- Evaluate patient requests for financial assistance
- Notify the Transplant clinical team of financial considerations that prevent or delay listing the patient for transplant
- Inform the Oncology Clinical team of financial considerations, seek clinical assistance as needed
- Refer patients to the Manufacturer Drug program and Pharmacy Assistance programs as needed for medications.
Obtaining Authorization and Prior Approval:
- Analyze benefit requirements and initiate the request for authorization / prior approval for the transplant evaluation, admission, clinic visits, donor compatibility, work-up and testing, organ procurement, and follow-up appointments
- Analyze benefit requirements and initiate authorization, pre- certifications and /or pre-determinations for chemotherapy treatments
- Work with clinical staff to obtain additional clinical information for benefit review in particular as it relates to clinical trials and off label drug use
- Prepare the medical packet (including letter of medical necessity and clinical evaluation) required for obtain prior approval, authorization, or pre-certification Document authorizations in Maestro Care per policy and procedure
- Review denials for evaluation and/or transplant and initiate the appeal process with the insurance payer working collaboratively with the patient, family, and physician
- Work collaboratively with the oncologists for treatment authorization denials and work proactively with the oncologist, drug manufacturer and payor to obtain coverage and prevent post billing authorization denials
Customer Service:
- Skilled at quickly building rapport with patients and often serve as the first point of contact for new transplant candidates.
- Have an in-depth knowledge of office/clinic procedures and practices associated with their assigned specialty.
- Screen callers and provide information and guidance based on knowledge of appli cable policies and procedures.
- Triage and respond to calls based on established protocols and standards.
- Resolve problems or complaints within departmental guidelines.
- Explain policies and procedures, and resolves pr oblems
- Gathers necessary documentation to support proper handling of in quiries/complaints
- Courtesy and professional conduct is maintained at a ll times
- Provides timely and effective service to internal customers
Case Management (Transplant):
- Set the next review date in the transplant registration screen to trigger the next period financial verification
- Request updates to the effective and termination dates of the transplant approval when expired
- Review outpatient appointments for active transplant registered patients and resolve any issues related to coverage and payment
- Identify operational improvements to maximize efficiency and effectiveness of services provided
- Communicate opportunities to management
- Perform other related duties incidental to the work described herein
On occasion overtime or weekend work may be required. Position may be subject to responding to urgent or emergent transplant team requests.
Minimum Qualifications
Education
High School Diploma required. Advanced degree preferred.
Experience
Three years of healthcare experience with a minimum of one year ininsurance verification, authorization, or billing experience required. One year of experience with a transplant or chemo therapy program preferred.
Degrees, Licensures, Certifications
Position may be subject to membership with the Transplant Financial Coordinators Association (for Transplant team)and may be subject to certification with TFCA.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
