Financial Clearance Specialist - Cost Infusions

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 as they seek or 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, it will determine benefit and coverage levels and connect 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

• 1. Verify patients’ insurance and benefits information for transplant, surgical, chemotherapy, and radiation therapy patients.
  • Understand various insurance carrier options and verify eligibility as outlined in departmental procedures.
  • Obtain insurance eligibility and benefits using the Online Eligibility system or any other means (telephone, fax, or third‑party payer website). When necessary, alert the appropriate staff of insufficient or terminated benefits.
  • Demonstrate a thorough understanding of Epic, Outlook, and the Online Eligibility system to determine insurance eligibility, initial pre‑certifications, and approvals.
  • Complete all pre‑certification notices prior to admission and initiate the notification process to the insurance company within 24‑48 hours of emergency admissions, escalating to management as needed when unresolved problems occur.
  • Alert the clinician involved in the patient’s care when there are issues with referrals or complications with insurance coverage.
  • Obtain all UB‑04 information and ensure compliance with healthcare regulations that govern hospital billing.
  • Determine medical necessity of scheduled services in accordance with CMS or other payer standards, and communicate coverage/eligibility information to patients.
  • Maintain a working knowledge of medical necessity for the pharmaceuticals and recurring services for this patient population.
  • Determine benefit and coverage levels and connect patients with financial assistance resources as needed.
• 2. Obtain prior authorizations from third‑party payers in accordance with payer requirements.
  • Utilize all necessary Epic applications from booking to obtain procedure codes as needed.
  • Read and interpret medical charts, synthesizing information to obtain necessary authorization from multiple documents and results.
  • Analyze results and prepare arguments for obtaining necessary authorizations.
  • Provide information to third parties to determine benefits and obtain the necessary approvals and authorizations to ensure accounts can be billed and payment received.
  • Educate patients and clinicians about the authorization process and make recommendations for improvements as needed.
  • Ensure that all subsequent follow‑up activity is established and adheres to a timely schedule.
  • Work with business office staff to understand and trend efforts for authorization‑related denials, aiming to reduce denials and improve workflows.
  • Maintain accurate records of authorizations with the EMR and payer sites.
• 3. Maintain professional approach at all times when communicating with patients, co‑workers, and payer representatives to…