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Clinical Review Navigator (PCMA Team) - 24 Hours per Week - Days - Remote
GENERAL SUMMARY:
Reports to Patient Billing and Financial Care Assistance (PBFCA) Leadership. Under minimal supervision, this position is responsible for assisting the Clinical Review Team screen uninsured, under- insured and insured patient care requests for medically necessity and urgency and ensuring that all financial responsibilities (current and prior balances) are addressed before services are rendered. Advises patients of available financial assistance programs and collaborates with physicians and other Henry Ford Health staff across all the organizational levels to determine continuing care needs.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
Identifies patients with inadequate access to resources; including health insurance coverage, primary care services and medications, and provides referrals to affordable community-based resources as appropriate.
Manages team's EPIC work queues to ensure that all financial responsibilities are addressed before services are scheduled and/or rendered.
Manages team's EPIC Department Appointment Report (DAR); documents all cases and follows to completion.
Conducts the initial review of care requests of uninsured and under-insured patients for financial assistance based on approved criteria. Prepares complex patient care requests for second and third level reviews by the Clinical Review Leader team for medical necessity and urgency.
Accurately registers and schedules appointments for approved patients based on the Clinical Review Team’s determination and scheduling protocols.
Handles all in-coming telephone activity, including answering phones promptly, according to system Quality standards; documents all interactions thoroughly, accurately, and legibly; takes accountability for cases through completion.
Identifies actual and potential problems with HFHS financial assistance programs, complex ambulatory HB & PB billing and denials, improves the patient care process and utilization of outpatient resources through the appropriate action and/or recommendation.
Assists patients with Medicare, Medicaid, Medicaid HMO, Marketplace and Commercial insurance enrollment, including but not limited to assessing the patients financial needs to determine the best plan.
Investigates and assists patients with internal and external financial assistance programs; including but not limited to Henry Ford Health Patient Financial Assistance Program applications, resources for care, Cobra payments, drug assistance, transportation, and collaborating with other HFH teams to prevent financial toxicity to the patient.
Investigates insurance plan authorization requirements and obtains required authorizations for ambulatory outpatient services when necessary.
Processes and reviews incoming Community Partner Referral (CPR) program voucher requests for ambulatory specialty services, ensuring they meet the qualifications of this uncompensated charity program.
Monitors and reviews CPR and CPR Lab only billed services for accuracy.
Collaborates with our CPR program Federally Qualified Health Clinic partners in the community.
Maintains strict confidentially standards for patient information. Complies with organizational, federal, and state regulations and policies on confidentiality.
Performs other related duties as required.
EDUCATION/EXPERIENCE REQUIRED:
High School Diploma or G.E.D. equivalent.
Associate's degree or two (2) years of college coursework in business, community health, social work, case management or a related field, preferred.
Two (2) years of experience working as a patient navigator, patient advocate, financial navigator or insurance verification specialist. Working Knowledge of Microsoft Office Suite.
Technical proficiency in EPIC applications such as Appointment Scheduling (all versions), Registrations, Work Queues and Referrals.
Knowledge of medical terminology preferred.
Bilingual, as appropriate to the work site. Ability to speak clearly and effectively.
Customer service-oriented including the ability to interact professionally and handle sensitive information/issues in a confidential, respectful, assertive, and empathetic manner in difficult interpersonal situations.
Ability to act in a manner that establishes positive rapport with patients, families, and public/private financial assistance programs.
Ability to quickly assess and respond appropriately to emergency situations.
Ability to comprehend medical terms.
Analytical skills to resolve complex problems requiring the use of scientific, mathematical, or technical principles, and in-depth experience in multi-tasking.
Ability to deliver consistent results and possess the drive to continually improve processes t
