• Interfaces with payors, medical groups, and review organizations to obtain appropriate authorizations for blood & marrow transplants. This requires a detailed understanding of the patient's disease and treatment plan, specific insurance review requirements, and protocol criteria.

• Gathers the necessary clinical information needed to obtain insurance authorization for transplantation. Communicates the authorization status of patients to the clinical team in person, by e-mail, and through the presentation this information in a detailed report at the weekly Master Schedule Meeting. This report indicates which patients have been authorized for transplant services. In cases where approval isn't in place, the report indicates the review status and lists any medical records or items that are still needed.

• Investigates insurance eligibility and obtains detailed insurance benefit verification for candidates. Benefit details include (but are not limited to) deductibles, co-payments and out-of-pocket expenses, coverage for donor services, policy maximums and limitations, and prescription drug coverage. Ensures that there are applicable contractual rates in place between SHC and the patient's insurance plan, or involves the Dept. of Managed Care in cases where there aren't applicable contractual rates in place.

• Analyzes insurance benefit details to ensure that patients have sufficient coverage and/or resources for transplantation. Provides financial consultation with patient and/or family members regarding financial aspects when necessary or requested. Determines deposit requirements when necessary. Assists patients in securing alternate methods of funding.

• Provides counsel to Physicians and the program team on any case where authorization isn't in place in time for a patient's start of treatment. Notifies Physician, Administrative Director, Financial Specialist and Nurse Coordinator by e-mail of any case where authorization isn't in place for treatment due to start within 3 business days. Offers expert opinion on likelihood of approval vs. the need for a delay of treatment.

• Identifies and documents insurance and authorization information and billing trigger dates in the Financial Database and EPIC. Interprets transplant contract language and disseminates information on insurance, authorizations, case rate coverage periods, and transplant billing triggers. Disseminates applicable information to Nurse Coordinators, Cancer Center financial staff, and billing teams.

• Active participant in program meetings, including but not limited to: New Patient Meeting, Master Schedule Meeting, meeting with PFS/PSO, BMT Operations staff meetings, and the Dept. of Managed Care Transplant Operations Meeting. Ensures that financial issues are recognized and addressed.

• Advises the Dept. of Managed Care if/when patients scheduled for treatment that requires an individual letter of agreement. Provides information needed by the contracting team to ensure that appropriate contractual rates are in place for transplant treatment.

• Other duties as assigned.

Education Qualifications

• High school diploma or GED required.

Experience Qualifications

• Two (2) years of progressively responsible and directly related work experience

Required Knowledge, Skills and Abilities

• Analytical skills- ability to anticipate and solve problems, analyze statistical date and recommend/implement solutions and improvements.

• Interpersonal skills- ability to work collaboratively with a culturally diverse staff and patient/family population, strong customer service skills, demonstrating tact and sensitivity in stressful situations.

• Office machine skills- must be computer proficient, including personal computers, and an ability and willingness to learn new systems and programs; experience with hospital information systems such as SMS, Cerner and IDX preferred.

• Basic medical terminology is required.

• Oral/written communication skills-demonstrates articulate and concise oral communications, as well as, the ability to write clearly and concisely.

Licenses and Certifications

• None

These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family's perspective:

• Know Me: Anticipate my needs and status to deliver effective care

• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health

• Coordinate for Me: Own the complexity of my care through coordination