The Financial Clearance Specialist is responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete in the time allowed by the insurance companies to prevent denials or penalties. Specialists are responsible for documenting accurate insurance information and authorization details to optimize reimbursement from both the payer and patient. The Specialist must maintain strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization.
Individuals must be able to run eligibility and secure full benefit coverage information (including COBRA when applicable) with insurance companies and employers, confirm all demographic information is correct, and ensure coordination of benefit (COB) and insurance plan codes are accurate. Specialists must verify insurance coverage immediately for inpatient and outpatient accounts that are same day and next day add-ons. Financial Clearance Specialists must determine if pre-certification, pre-authorization or a referral is required for insurance companies and obtain if applicable. The individual will be expected to communicate with providers and team regarding out-of-network issues, assess contracted and non-contracted payer issues, and document outcomes and next steps.
Specialists must also determine, communicate, and collect patient liability prior to service and attempt to collect prior balances. Representatives are to conduct all transactions appropriately and consistently, and complete Medicare Secondary Questionnaire accurately with the patient or patient's representative. Specialists must maintain compliance with HIPAA regulations as it pertains to the insurance processes. Representatives must maintain professional development by attending workshops, in-services, and webinars to remain up-to-date on insurance rules and regulations in addition to changes within the industry.
Financial Clearance Specialist III must have the ability to submit authorizations for surgery, chemotherapy, transplants, and all other complex services. Must be able to verify insurance and advanced knowledge of both CPT codes and medical terminology. Must also be able to understand and interpret patient liability and benefits for HMOs and all payer types.