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, as individuals and professionals, every day.
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. When physicians and clinicians make care decisions, the Financial Clearance Specialist is aware of how a patient's benefits fit into the care plan, and keeps patients and physicians informed of such as they seek of obtain authorizations from payers. This position is responsible for the financial clearance of transplant, surgical, chemotherapy, and radiation therapy patients, including insurance verification, price estimation, and validation of medical necessity for certain services. This position will maintain a proficient understanding of third-party payer regulations and guidelines for these particular service lines, including a working knowledge of medical necessity requirements for the pharmaceuticals and recurring services that these patients often require. In addition, will determine benefit and coverage levels and connects patients with financial assistance resources as needed. In all encounters with patients and families, the Financial Clearance Specialist will strive for the highest level of customer service.
EEO/AA/Disability/Veteran
Responsibilities:
- Verifies patients' insurance and benefits information for transplant, surgical, chemotherapy, and radiation therapy patients.
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Exhibits understanding of various insurance carrier options and verifies eligibility as outlined in departmental procedures.
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Obtains insurance eligibility and benefits utilizing the On-line Eligibility system or any other means (i.e. telephone, fax or various third party payer website). When necessary, alerts the appropriate staff of insufficient and/or termination of benefits.
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Demonstrates a thorough understanding of Epic, Outlook, and On-line Eligibility system in order to determine insurance eligibility, initial pre-certifications, and approvals.
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Completes all pre-certification notices prior to admission and initiates the notification process to the insurance company within 24-48 hours of emergency admissions escalating to management as needed when unresolved problems occur.
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Alerts the clinician involved in the patient's care when there are issues with referrals or complications with insurance coverage.
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Obtains all UB-04 information and ensures compliance with health care regulations that govern hospital billing.
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Determines medical necessity of scheduled services in accordance with Centers for Medicare & Medicaid Services (CMS) or other payer standards, and communicates coverage/eligibility information to patients.
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Maintains a working knowledge of medical necessity for the pharmaceuticals and recurring services for this patient population.
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Determines benefit and coverage levels and connects patients with financial assistance resources as needed.
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Obtains prior authorizations from third-party payers in accordance with payer requirements.
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Utilizes all necessary Epic applications from booking to obtain procedure codes as needed.
- Reads and interprets medical chart including synthesizing medical information to obtain necessary authorization from multiple documents, results, etc.
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Analyzes results and prepares arguments for obtaining necessary authorizations.
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Provides information to the third parties to determine benefits and obtains the necessary approvals and authorizations to ensure accounts can be billed and payment received.
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Educates patients and clinicians about the authorization process and makes recommendation(s) for improvements as needed.
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Ensures that all subsequent follow-up activity is established and adheres to a timely schedule.
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Works with business office staff to understand/trend efforts for authorization-related denials resulting in reduced denials. Looks to improve workflows to reduce volume.
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Maintains accurate records of authorizations with the EMR and payer sites.
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Maintains professional approach at all times when communicating with patients, co-workers, and payer representatives to ensure a positive and professional experience.
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Contacts patients as needed to gather demographic and insurance information, and updates patient information within the EMR as necessary.
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Informs the patient whether the authorization for the referral has not been approved.
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Provides patient liability estimate and educates patient on their insurance benefits as necessary.
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Requests pre-service payment for patient liability and/or arranges payment plans using appropriate guidelines.
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Identifies events where Service Recovery is appropriate. Initiates corrective actions and follows through to ensure that not only the recovery is completed but also reoccurrences do not occur.
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Performs other duties as assigned by Supervisor to support revenue cycle operations.
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Maintains a proficient understanding of third-party payer regulations and guidelines for transplant, surgical, chemotherapy, and radiation therapy service lines, including a working knowledge of medical necessity requirements for the pharmaceuticals and recurring services that these patients often require.
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Presents facts in a logical pattern and completes summaries to be presented to upper management.
- Contributes to the financial vitality of the organization by thoroughly understanding key operational dependencies (insurance eligibility, referrals, authorizations, etc.).
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Identifies and recommends opportunities to improve Patient Access or Financial Clearance activities.
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Identifies, researches, and resolves any issues that may cause delays in service.
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Participates in ongoing quality improvement efforts of the department , utilizing good problem solving methods and resourcefulness to address and resolve problems or to refer them to the appropriate person or department for resolution.
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Keeps abreast of changing federal, state, and departmental policies/procedures.
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Maintains the 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 with work in healthcare or business preferred. 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 and ability to prioritize tasks. Excellent verbal and written communication skills. Strong interpersonal skills and ability to build rapport with a wide variety of individuals. Advanced working knowledge of code sets required. Basic understanding of diagnostic testing and procedure codes (CPT, HCPCS, ICD-9-CM/PCS, and ICD-10-CM/PCS coding, etc.). Maintains a proficient understanding of third-party payer regulations and guidelines for transplant, surgical, chemotherapy, and radiation therapy service lines, including a working knowledge of medical necessity requirements for the pharmaceuticals and recurring services that these patients often require. Demonstrates attention to detail and ability to multitask. Advanced knowledge of Microsoft Office, Word, and Excel.
