The primary purpose of the Insurance Verifier/Financial Advisor position is to ensure that appropriate reimbursement resources are in place for services provided, or that patients are screened for potential Medi-Cal or Charity Care qualification if they are not insured or are underinsured.  This includes the following: 

1) Verification of demographic and insurance information provided.

2) Accurate and timely determination of payer and patient liability, and notifications and initial authorizations required.

3) Validate that required authorizations for elective surgery and notification of admissions are obtained for initial hospital stay.

4) Adherence to government and non-government program requirements.

5) Communicating effectively and/or discuss with patients as to benefits, program requirements, and patient financial responsibility.

6) Provides options for care and placement that allow for informed decisions by the patient and his/her family while protecting the financial interest of the AHMC Seton Medical Center. 7) Provides information for uninsured and underinsured patients regarding the self-pay discounts and Financial Assistance (Charity program) when no other options are available.

8) Sets up payment arrangements as needed.  

9) Other Duties as assigned.

1.  General Duties

Performs insurance verifications, insurance notifications, obtains tracking numbers as applicable of all Direct, Urgent and Elective admissions, observation services and procedures

Advises patients and/or family members and Case Management (as applicable) of insurance benefits, exclusions and financial obligations.  Determines primary coverage when multiple insurances are involved, collects and verifies insurance eligibility as it applies to services rendered, collects payments, deposits and/or arranges for payment plans if necessary.

Obtains signed patient acknowledgement of financial responsibility, interviews patients as referred, obtains and completes information for MSP, coordination of benefits (COB) and other regulatory forms as required, collaborates with AHMC Seton Medical Center Business Services collections staff to monitor patient accounts.

Determines patient third party insurance coverage and/or government programs, validates benefits pertinent   to services provided at Seton Medical Center. Gathers and analyzes all patient information on medical needs, financial resources and circumstances, residential status, duration/type of care, patient eligibility for private, federal, state and county program coverage; provide full documentation for billing within limits specified by the appropriate agency and coverage source

Interpret and relay provisions and requirements of applicable private, federal, state and county aide programs to patients, case managers and physicians, explaining all obligations and rights under the given programs.

Ensures appropriate authorizations and/or TARs are obtained prior to elective services being provided.  

Provide all alternatives at hand and counsel patients regarding realistic financial ability to pay for medical care. Interview and correspond with patients, relatives, attorneys, employers and welfare agencies to obtain information, explain policies, receive payment and arrange payment plans.  Documents all pertinent information and financial counseling activities in accordance with department and /or regulatory policies and/ or procedures.

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Advises patients and/or family members and Case Management (as applicable) of insurance benefits, exclusions and financial obligations.  Determines primary coverage when multiple insurances are involved, collects and verifies insurance eligibility as it applies to services rendered, collects payments, deposits and/or arranges for payment plans if necessary.

Resolve problems involving interfacing of various private and government agencies to ensure appropriate billing and reimbursement for services.

Apply sensitivity to the patient’s medical situation in the counseling of a patient about his/her financial relationship to services provided to minimize impact during care while assuring that the patient can make informed choices about it.

Interact professionally with AHMC Seton Medical Center Central Business Office staff to obtain all pertinent information protecting patient confidentiality while ensuring all components required for reimbursement are obtained. 

Define the Charity Care policy, provide charity or financial assistance applications, and provide Medi-cal applications to patients. Works closely with the patient and/or patient’s family to obtain required information and review final determination. 

 Calculates figures and amounts such as adjustments, discounts, proportions, and percentages for account accuracy

Assists patients when requested with billing inquiries, patient financial liability and insurance payment issues. Requests adjustments, refunds, validate all authorizations for credit card payments and credibility of personal checks.

Maintains knowledge of all insurance/managed care requirements and procedures 

Performs other duties and accepts responsibility as assigned.

• The employee must frequently lift up to 25 pounds and push/pull up to 25 pounds.  Specific vision abilities required by this job include close vision.
• The duties of this job include possible exposure to gases and fumes, blood and body fluids, and hazardous chemicals; the employee must understand and demonstrate the ability to take protective actions, following established guidelines.  The noise level in the work environment is usually quiet.