Job Description Summary
The Financial Counselor is responsible for evaluating scheduled patient visits to identify and resolve funding/coverage with either assistance applying for Medicaid, disability, financial assistance, insurance coverage or resources identified revealing the ability to pay out of pocket for MUSC Health Services, and provide patients copayments/deductible/deposit information to be paid prior to services rendered.
Entity
MUSC Community Physicians (MCP)
Worker Type
Employee
Worker Sub-Type
Regular
Cost Center
CC004513 MCP - Revenue Cycle
Pay Rate Type
Hourly
Pay Grade
Health-24
Scheduled Weekly Hours
40
Work Shift
Job Description
Job Purpose:
The Financial Counselor (Infusion) serves as the primary financial and information resource for patients receiving infusion therapy. The position provides estimates for infusion drugs and administration services, verifies insurance benefits, establishes and communicates patient financial responsibility, that will allow prescribed therapy to be financially attainable. This is a specialized role supporting high-cost drug therapy in an environment where payer requirements, drug costs, and available funding change frequently. The position works independently, researching and resolving unfamiliar and non-routine cases from initiation through conclusion, and serves as a liaison among patients, providers, pharmacy staff, payers, and outside assistance programs.
Primary Job Duties & Responsibilities:
- Verify insurance eligibility and benefits specific to infusion therapy, including medical versus pharmacy benefit determination, deductible, coinsurance, out-of-pocket maximum, site-of-care requirements, and any drug-specific coverage limitations.
- Research and interpret payer medical policy and drug coverage criteria for new, changing, and high-cost infusion therapies. Identify coverage barriers early and communicate them to the provider, pharmacy, and nursing teams before treatment is scheduled.
- Coordinate with provider and pharmacy teams to obtain letters of medical necessity, supporting clinical documentation, and peer-to-peer reviews.
- Review assigned patient(s) and/or Physician schedules for upcoming visits and/or treatment to establish patient financial responsibility.
- Review patients’ treatment plan(s) and identify if insurance benefit coverage is active and patient fiscal responsibility, all unplanned exceptions are to be communicated to provider immediately.
- Review and identify new treatment orders, generate an estimate of service and review with patient explaining insurance benefits and fiscal responsibility.
- If applicable, obtain necessary information from patients for assistance income guidelines.
- Discuss and explain forms and paperwork needed such as waivers, treatment estimates, payment plans, assistance applications, etc.
- Provide general, non-directive education on coverage options, including basic Medicare enrollment periods and plan structures, and refer patients to the State Health Insurance Assistance Program (SHIP), licensed brokers, Medicaid eligibility vendors, or the health system financial assistance team for plan selection and enrollment decisions. This position does not recommend, endorse, or select specific insurance plans on behalf of patients.
- Communicate openly and routinely throughout the course of the workday with providers, nursing staff, coworkers through Teams, phone calls, emails and in person to discuss fiscal responsibility and other items as needed.
- Independently manage an assigned caseload, including researching unfamiliar drugs, payer requirements, and funding sources, and carrying non-routine issues from identification through resolution. Escalate to provider, pharmacy, or revenue cycle leadership when an issue exceeds the scope or authority of the position.
- Understand and comply with all Federal and State laws and regulations pertaining to patient care, rights, safety, billing, and collections.
- Adhere to all departmental policies and procedures, including Revenue cycle policies and procedures.
- Performs other duties as assigned.
Education and Work Experience
High school diploma and five (5) years of medically related customer service, insurance, and/or collections experience required, OR bachelor’s degree and one (1) year of customer service, insurance verification, and/or prior authorization experience in an infusion, oncology, or specialty pharmacy setting. Knowledge of medical terminology and computer proficiency are required, including typing, Microsoft Excel, and Microsoft Word. Epic experience is preferred, particularly referral and authorization workflows. Experience obtaining prior authorization for infusion or injectable drugs, and familiarity with manufacturer copay assistance programs and foundation grant funding, is strongly preferred. The candidate must be punctual, dependable, highly organized, self-motivated, goal-oriented, and able to demonstrate excellent verbal and written communication skills. The role requires the ability to work independently with minimal direction, resolve unfamiliar problems where little precedent exists, establish and maintain effective working relationships, demonstrate professionalism, and continuously seek opportunities for professional growth and improvement.
- Prior healthcare customer service experience.
- Working knowledge of medical terminology.
- Prior medical insurance verification experience, including determination of medical versus pharmacy benefit coverage.
- Excellent verbal and written communication skills.
- Insurance knowledge including an understanding of medical terminology, ICD-10, CPT, and HCPCS Level II (J-code) drug billing conventions, including NDC and unit reporting.
- Prior cash handling and monetary collection experience.
- Ability to calculate and collect patients’ responsibility and insurance co-pay/coinsurance.
- Experience enrolling patients in and managing manufacturer copay assistance programs, foundation grants, or other third-party funding sources.
- Demonstrated ability to work independently, research unfamiliar issues, and carry a problem through to resolution without day-to-day direction.
Degree of Supervision
Works under limited supervision and exercises a high degree of independent judgment. The position requires the ability to analyze situations, determine appropriate next steps, and follow through to achieve expected outcomes without prompting. Because payer requirements, drug coverage criteria, and funding sources change frequently, the incumbent must be able to research and resolve unfamiliar problems independently, from initiation