Financial Clearance Specialist

Job Title

Under general supervision, responsible for processing the patient, insurance and financial clearance aspects for both scheduled and non-scheduled appointments, including validation of insurance and benefits, routine and complex pre-certification, prior authorizations, and scheduling/pre-registration. Responsible for triaging routine financial clearance work.

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Processes administrative and financial components of financial clearance including, validation of insurance/benefits, medical necessity validation, routine and complex pre-certification, prior-authorization, scheduling/pre-registration, patient benefit and cost estimates, as well as pre-collection of out of pocket cost share and financial assistance referrals.

2. Initiates and tracks referrals, insurance verification and authorizations for all encounters.

3. Utilizes third party payer websites, real-time eligibility tools, and telephone to retrieve coverage eligibility, authorization requirements and benefit information, including copays and deductibles.

4. Works directly with physician's office staff to obtain clinical data needed to acquire authorization from carrier.

5. Inputs information online or calls carrier to submit request for authorization; provides clinical back up for test and documents approval or pending status.

6. Identifies issues and problems with referral/insurance verification processes; analyzes current processes and recommends solutions and improvements.

7. Reviews and follows up on pending authorization requests.

8. Coordinates and schedules services with providers and clinics.

9. Researches delays in service and discrepancies of orders.

10. Assists management with denial issues by providing supporting data.

11. Pre-registers patients to obtain demographic and insurance information for registration, insurance verification, authorization, referrals and bill processing.

12. Develops and maintains a working rapport with inter-departmental personnel including ancillary departments, physician offices, and financial services.

13. Assists Medicare patients with the Lifetime Reserve process where applicable.

14. Reviews previous day admissions to ensure payer notification upon observation or admission.

15. Must be willing to travel between facilities as needed (applies to specific UMMS Facilities).

16. Performs other duties as assigned.

Education and Experience

1. High School Diploma or equivalent is required.

2. Minimum two years of experience in healthcare revenue cycle, medical office, hospital, patient access or related experience.

3. Experience in healthcare registration, scheduling, insurance referral and authorization processes preferred.

Knowledge, Skills and Abilities

1. Knowledge of medical and insurance terminology.

2. Knowledge of medical insurance plans, especially manage care plans.

3. Ability to understand, interpret, evaluate, and resolve basic customer service issues.

4. Excellent verbal communication, telephone etiquette, interviewing, and interpersonal skills to interact with peers, superiors, patients, and members of the healthcare team and external agencies.

5. Intermediate analytical skills to resolve problems and provide patient and referring physicians with information and assistance with financial clearance issues.

6. Basic working knowledge of UB04 and Explanation of Benefits (EOB).

7. Some knowledge of medical terminology and CPT/ICD-10 coding.

8. Demonstrate dependability, critical thinking, and creativity and problem-solving abilities.

9. Knowledge of registration and admitting services, general hospital administrative practices, operational principles, The Joint Commission, federal, state, and legal statutes preferred.

10. Knowledge of the Patient Access and hospital billing operations of Epic preferred.