Financial Clearance Specialist

Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient‑centered, respect, accountability, and compassion—must guide what we do. The Financial Clearance Specialist is responsible for ensuring that payers are prepared to reimburse Corporate Business Services (CBS) for scheduled services in accordance with the payer‑provider contract. The role plays an active part in the clinical decision process by understanding how a patient’s benefits fit into the care plan and keeping patients and physicians informed to obtain authorizations from payers. The specialist manages financial clearance for transplant, surgical, chemotherapy, and radiation therapy patients, including insurance verification, price estimation, and validation of medical necessity for certain services. They maintain knowledge of third‑party payer regulations and guidelines and determine benefit and coverage levels while connecting patients with financial assistance resources as needed. All interactions with patients and families are approached with the highest level of customer service. EEO/AA/Disability/Veteran We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected status. Responsibilities Verifies patients’ insurance and benefits information for transplant, surgical, chemotherapy, and radiation therapy patients Exhibits understanding of various insurance carrier options and verifies eligibility as outlined in departmental procedures. Obtains insurance eligibility and benefits utilizing the On‑line Eligibility system or other means (telephone, fax, or payer website). Alerts staff of insufficient or terminated benefits. Demonstrates thorough understanding of Epic, Outlook, and the On‑line Eligibility system to determine eligibility, pre‑certifications, and approvals. Completes all pre‑certification notices prior to admission and initiates notification to the insurance company within 24–48 hours of emergency admissions, escalating to management when unresolved. Alerts clinicians of referral or coverage issues. Obtains all UB‑04 information and ensures compliance with regulations governing hospital billing. Determines medical necessity of scheduled services per CMS or payer standards and communicates coverage/eligibility to patients. Maintains a working knowledge of medical necessity for pharmaceuticals and recurring services for this population. Determines benefit and coverage levels and connects patients with financial assistance as needed. Obtains prior authorizations from third‑party payers in accordance with payer requirements Utilizes Epic applications from booking to obtain procedure codes. Reads and interprets medical charts, synthesizing information to obtain necessary authorizations. Analyzes results and prepares arguments for necessary authorizations. Provides information to third parties to determine benefits and obtains approvals to ensure accounts can be billed and paid. Educates patients and clinicians about the authorization process and recommends improvements. Ensures all subsequent follow‑up activity is established and adheres to a timely schedule. Works with business office staff to trend authorization‑related denials, aiming to reduce volume. Maintains accurate records of authorizations in the EMR and payer sites. Maintains a professional approach at all times when communicating with patients, co‑workers, and payer representatives Contacts patients to gather demographic and insurance information, updating the EMR as needed. Informs patients when an authorization has not been approved. Provides patient liability estimate and educates on insurance benefits. Requests pre‑service payment, arranges payment plans according to guidelines. Identifies events where service recovery is appropriate, initiates corrective action, and ensures completion. Performs other duties as assigned by the supervisor to support revenue cycle operations Maintains understanding of payer regulations and guidelines for transplant, surgical, chemotherapy, and radiation therapy service lines. Provides logical presentation of facts and completes summaries for upper management. Contributes to the organization’s financial vitality by understanding key operational dependencies. Identifies and recommends opportunities to improve Patient Access or Financial Clearance activities. Researches and resolves issues that may cause service delays. Participates in ongoing quality improvement efforts, using problem‑solving methods and resources. Keeps abreast of changing federal, state, and departmental policies and procedures. Maintains required CRCS or equivalent certification for Access Professionals and CPC, LPN, Pharmacology License or other medical degree or equivalent. Qualifications Education —High school graduate or GED required. Bachelor's degree preferred. CPC, LPN, Pharmacology License or other medical degree or equivalent preferred. CRCS or equivalent certification for Access Professionals required within 18 months of hire. Certified Medical Assistant (CMS), Licensed Practical Nurse (LPN), or Certified Professional Coder (CPC) status preferred. Experience —Three (3) to four (4) years of work experience with insurance authorization/verification of benefits, revenue cycle functions, hospital/physician offices, or related areas preferred. Licensure —Certified Medical Assistant (CMS), Licensed Practical Nurse (LPN), or Certified Professional Coder (CPC) status preferred. Special Skills —Strong organizational skills, ability to prioritize tasks; excellent verbal and written communication; strong interpersonal skills; advanced working knowledge of code sets; basic understanding of diagnostic testing and procedure codes (CPT, HCPCS, ICD-9-CM/PCS, ICD-10-CM/PCS); proficient in Microsoft Office (Word, Excel); attention to detail; ability to multitask. YNHHS Requisition ID: 176643 #J-18808-Ljbffr Yale New Haven Health