Financial Clearance Specialist - Specialty Rx

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.

EEO/AA/Disability/Veteran

• 1. Verifies patients' insurance and benefits information for transplant, surgical, chemotherapy, and radiation therapy patients.
  • 1.1 Exhibits understanding of various insurance carrier options and verifies eligibility as outlined in departmental procedures.
  • 1.2 Obtains insurance eligibility and benefits utilizing the Online 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.
  • 1.3 Demonstrates a thorough understanding of Epic, Outlook, and Online Eligibility system in order to determine insurance eligibility, initial pre-certifications, and approvals.
  • 1.4 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.
  • 1.5 Alerts the clinician involved in the patient's care when there are issues with referrals or complications with insurance coverage.
  • 1.6 Obtains all UB-04 information and ensures compliance with health care regulations that govern hospital billing.
  • 1.7 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.
  • 1.8 Maintains a working knowledge of medical necessity for the pharmaceuticals and recurring services for this patient population.
  • 1.9 Determines benefit and coverage levels and connects patients with financial assistance resources as needed.
• 2. Obtains prior authorizations from third-party payers in accordance with payer requirements.
  • 2.1 Utilizes all necessary Epic applications from booking to obtain procedure codes as needed.
  • 2.2 Reads and interprets medical chart including synthesizing medical information to obtain necessary authorization from multiple documents, results, etc.
  • 2.3 Analyzes results and prepares arguments for obtaining necessary authorizations.
  • 2.4 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.
  • 2.5 Educates patients and clinicians about the authorization process and makes recommendation(s) for improvements as needed.
  • 2.6 Ensures that all subsequent follow-up activity is established and adheres to a timely schedule.
  • 2.7 Works with business office staff to understand/trend efforts for authorization-related denials resulting in reduced denials. Looks to improve workflows to reduce volume.
  • 2.8 Maintains accurate records of authorizations with the EMR and payer sites.
• 3. Maintains professional approach at all times when communicating with patients, co-workers, and payer representatives to ensure a positive and professional experience.
  • 3.1 Contacts patients as needed to gather demographic and insurance information, and updates patient information within the EMR as necessary.
  • 3.2 Informs the patient whether the authorization for the referral has not been approved.
  • 3.3 Provides patient liability estimate and educates patient on their insurance benefits as necessary.
  • 3.4 Requests pre-service payment for patient liability and/or arranges payment plans using appropriate guidelines.
  • 3.5 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.
• 4. Performs other duties as assigned by Supervisor to support revenue cycle operations.
  • 4.1 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…