Insurance and Financial Clearance Specialist

POSITION SUMMARY: The Insurance & Financial Clearance Specialist plays a critical role within the Revenue Cycle team by ensuring patients are financially cleared prior to treatment or medication dispensing. This position is responsible for verifying insurance eligibility, determining medical and pharmacy benefits, identifying referral and authorization requirements, coordinating benefits, and estimating patient financial responsibility. By ensuring accurate insurance information and financial clearance before services are provided, the specialist helps reduce reimbursement delays, improve the patient experience, and support an efficient revenue cycle. This role serves as the primary liaison between scheduling, clinical staff, billing, and the Prior Authorization Coordinators to ensure all payer requirements are identified before medication dispense or treatment. The Insurance & Financial Clearance Specialist identifies authorization requirements but does not obtain or submit prior authorizations. KEY RESPONSIBILITIES: Verify patient insurance eligibility and active medication coverage. Determine applicable medical and pharmacy benefits and identify the appropriate benefit under which services or medications will be billed. Review payer benefits to determine deductibles, copayments, coinsurance, out-of-pocket maximums, and other patient financial obligations. Coordinate primary, secondary, and tertiary insurance benefits to ensure accurate billing sequence. Identify payer requirements, including referrals, authorization requirements, and benefit limitations, and communicate findings via the Next Gen tasking work queue to the Prior Authorization Coordinator when authorization is required. Verify network participation, coverage limitations, frequency limitations, and payer-specific requirements. Ensure all insurance and demographic information is accurate and complete within Next Gen, New Leaf, and R2. Calculate and document estimated patient financial responsibility using established estimation tools and payer information. Collaborate with scheduling, clinic staff, pharmacy, billing, and the Prior Authorization Coordinator to facilitate timely financial clearance before medications are dispensed. Document all insurance verification activities, benefit information, and patient communications accurately and thoroughly. Resolve insurance eligibility discrepancies by working directly with patients, insurance carriers, employers, or referral sources as appropriate. Maintain assigned work queues and complete financial clearance activities within established service level expectations. Refer patients to the Patient Access Navigator when financial assistance or additional support may be needed. Support organizational goals by helping reduce registration errors, billing delays, and avoidable claim denials through accurate front-end insurance verification. Maintain compliance with HIPAA, payer guidelines, and organizational policies and procedures. Other job duties as assigned. WHAT SUCCESS LOOKS LIKE: Consistently verify insurance eligibility, medical and pharmacy benefits, and payer requirements accurately and within established service-level expectations. Identify the correct benefit and billing pathway for medications and services, including coordination of primary, secondary, and tertiary coverage. Accurately determine and document patient financial responsibility, including deductibles, copayments, coinsurance, and out-of-pocket obligations. Identify referrals, prior authorization requirements, benefit limitations, network restrictions, and other payer requirements before services are provided or medications are dispensed. Communicate payer requirements clearly and promptly to the appropriate internal teams, particularly the Prior Authorization Coordinator, through established workflows and Next Gen tasking. Maintain accurate and complete insurance and demographic information across Next Gen, New Leaf, and R2. Keep assigned work queues current and complete financial clearance activities within established productivity and turnaround-time expectations. Resolve insurance discrepancies proactively and effectively, minimizing delays to patient care and reducing avoidable billing issues and claim denials. Recognize when patients may benefit from financial assistance or additional support and appropriately connect them with the Patient Access Navigator. Contribute to a positive patient experience by communicating financial and insurance information clearly, respectfully, and with appropriate sensitivity. Demonstrate consistent compliance with HIPAA, payer requirements, organizational policies, and applicable regulatory standards. Help strengthen WACBD's overall revenue cycle by improving front-end accuracy, reducing reimbursement delays, and preventing avoidable denials. QUALIFICATIONS: Preferred: Bachelor’s degree in healthcare administration, business administration, public health, or health sciences. Certification from HFMA, AAPC, or AHIMA related to revenue cycle billing and collections, patient access, financial clearance, or HCPCS/CPT coding. Required: Associate's degree in healthcare administration, business administration, public health, or health sciences. Or, a relevant combination of education and experience may be considered in lieu of formal education requirements. At least two years of experience in healthcare patient access, insurance verification, financial clearance, revenue cycle, medical billing, or a closely related healthcare administrative role. Working knowledge of health insurance concepts, including eligibility, benefits, deductibles, copayments, coinsurance, out-of-pocket maximums, coordination of benefits, and network participation. Experience verifying medical and/or pharmacy insurance benefits and identifying payer-specific coverage requirements. Demonstrated ability to accurately interpret insurance information and determine patient financial responsibility. Experience working with electronic health records, practice management systems, insurance portals, or other healthcare information systems. Strong attention to detail and the ability to maintain accurate records across multiple systems. Ability to manage multiple priorities, work independently, and consistently meet established deadlines and service-level expectations. Strong written and verbal communication skills, with the ability to communicate effectively with patients, insurance carriers, employers, referral sources, and internal teams. Demonstrated ability to protect confidential patient information and maintain HIPAA compliance. Ability to exercise sound judgment when identifying insurance discrepancies, coverage issues, and payer requirements. Ability to work effectively as part of a multidisciplinary team and collaborate across departments. #J-18808-Ljbffr Socket.dev