[Hiring] Financial Clearance Specialist @Yale New Haven Health

Role Description

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. Key responsibilities include:

• Verifying patients' insurance and benefits information for transplant, surgical, chemotherapy, and radiation therapy patients.
• Exhibiting understanding of various insurance carrier options and verifying eligibility as outlined in departmental procedures.
• Obtaining insurance eligibility and benefits utilizing the On-line Eligibility system or other means (i.e. telephone, fax, or various third-party payer websites).
• Demonstrating a thorough understanding of Epic, Outlook, and On-line Eligibility system to determine insurance eligibility, initial pre-certifications, and approvals.
• Completing all pre-certification notices prior to admission and initiating the notification process to the insurance company within 24-48 hours of emergency admissions.
• Alerting the clinician involved in the patient's care when there are issues with referrals or complications with insurance coverage.
• Obtaining all UB-04 information and ensuring compliance with health care regulations that govern hospital billing.
• Determining medical necessity of scheduled services in accordance with Centers for Medicare & Medicaid Services (CMS) or other payer standards.
• Maintaining a working knowledge of medical necessity for pharmaceuticals and recurring services for this patient population.
• Determining benefit and coverage levels and connecting patients with financial assistance resources as needed.
• Obtaining prior authorizations from third-party payers in accordance with payer requirements.
• Utilizing all necessary Epic applications from booking to obtain procedure codes as needed.
• Reading and interpreting medical charts to obtain necessary authorization from multiple documents.
• Analyzing results and preparing arguments for obtaining necessary authorizations.
• Providing information to third parties to determine benefits and obtaining necessary approvals and authorizations.
• Educating patients and clinicians about the authorization process and making recommendations for improvements.
• Ensuring that all subsequent follow-up activity is established and adheres to a timely schedule.
• Working with business office staff to understand/trend efforts for authorization-related denials.
• Maintaining accurate records of authorizations with the EMR and payer sites.
• Maintaining a professional approach at all times when communicating with patients, co-workers, and payer representatives.
• Contacting patients as needed to gather demographic and insurance information.
• Informing the patient whether the authorization for the referral has not been approved.
• Providing patient liability estimates and educating patients on their insurance benefits.
• Requesting pre-service payment for patient liability and/or arranging payment plans.
• Identifying events where Service Recovery is appropriate and initiating corrective actions.
• Performing other duties as assigned by Supervisor to support revenue cycle operations.
• Presenting facts in a logical pattern and completing summaries for upper management.
• Identifying and recommending opportunities to improve Patient Access or Financial Clearance activities.
• Participating in ongoing quality improvement efforts of the department.
• Keeping abreast of changing federal, state, and departmental policies/procedures.
• Maintaining the required CRCS or equivalent certification for Access Professionals and other relevant licenses.

Qualifications

• 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.

Requirements

• 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.
• 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.).
• Demonstrates attention to detail and ability to multitask.
• Advanced knowledge of Microsoft Office, Word, and Excel.

Company Description