Financial Clearance Specialist

Job Description Summary

The Financial Clearance Specialist is responsible for obtaining precertification/ prior authorization for inpatient admissions, surgical procedures, and outpatient clinical services. The Financial Clearance Specialist secures financial clearance for each admission in accordance to payer guidelines and escalates financial clearance concerns through prompt and closed loop communication. Collaborates and reviews financial clearance data with the Patient Access Supervisor and Manager to ensure proper authorization for all services is obtained. The Financial Clearance Specialist is responsible for verification of insurance benefits with all insurance carriers.

Job Description

ESSENTIAL FUNCTIONS

1. Works independently to complete daily assignments by the end of the shift and long term assignments by established deadline and will inform supervisor when unable to meet deadline for guidance.

2. Meets management targets for authorization accuracy rates and falls within the standard of no greater than five administrative denials. 

3. Adhere to current department processes and all South Shore Health and external policies and/or procedures which may affect reimbursement.

4. Collaborate with internal and external stakeholders to achieve best outcome for patients and the health systems revenue cycle.

5. Working knowledge of Common Procedural Terminology (CPT), Health Care Procedural Coding System (HCPCS) coding and International Classification of Diseases (ICD-10).

6. Knowledge of payer policies for medical necessity/authorization requirements.

7. Collect, verify, and record all patient demographic and insurance information required per hospital policy.

8. Ensures all possible coverages are created and verified, through electronic or manual methods, and all discrepancies are resolved using RTE and Passport OneSource.

9. Adheres to identifying accurate patient information.

10. Determine, provide, and collect patient out of pocket costs when applicable, including copayments and estimates.

11. Able to identify and transcribe ICD-10 diagnosis and procedure CPT codes

12. Ability to successfully navigate computer software systems to adhere to department standards; including EPIC, Workday, insurance verifications portals, API (timecard), and Medicare/Medicaid systems.

13. Manage assignments by utilizing Faxcom programming and manual faxing to external vendors.

14. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

15. Embraces technological advances that allow us to communicate information effectively and efficiently based on role and complies with all regulatory agencies.

16. Maintains the confidentiality and privacy of protected health information consistent with HIPAA requirements at all times.

17. Observes hospital and department policies and procedures.

18. Maintains a high level of accuracy of all information conveyed in an authorization request and addresses errors in a timely fashion.

19. Understands the impact that data collected has on hospital operations.

20. Adheres to universal precautions and respiratory etiquette guidelines    

JOB REQUIREMENTS

Minimum Education - Preferred

High school diploma, two (2) years of college preferred.

Minimum Work Experience

Minimum one (1) year Financial Clearance experience to become proficient.

Required additional Knowledge and Abilities

•    Ability to work independently with minimal need for supervision

•    Ability to work in a fast paced environment to ensure completion of daily caseload within appropriate time frames.

•    Positive attitude and strong desire to positively contribute to the team

•    Knowledge of hospital EHR systems in EPIC

•    Ability to identify, analyze and resolve problems and situations quickly and effectively 

•    Strong knowledge of overall Revenue Cycle operations related to healthcare

Medical terminology. Insurance Knowledge Computer skills Strong knowledge of third party insurance required Ability to follow through and troubleshoot Attention to detail Customer Service skills Organizational skills Ability to work well within a team.