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 Representative is responsible for ensuring that payers are prepared to reimburse for scheduled services in accordance with the payer-provider contract. When physicians and clinicians make care decisions, this individual is aware of how a patient?s benefits fit into the care plan, and keeps patients and physicians informed of such as they seek to obtain authorizations from payers. This role contacts payers to request service authorization and may collect financial and/or demographic information from patients as needed. In all encounters with patients, families, physicians and their staff will strive for the highest level of customer service. The efficiency of obtaining accurate information, while providing excellent customer service is an essential function of this job.
Responsibilities: 1. Verifies patients'' insurance and benefits information. 1.1 Responsible for any verification (IP and OP) of authorizations obtained by non YNHHS, YMG, NEMG. 1.2 Exhibits understanding of various insurance carrier options and verifies eligibility as outlined in departmental procedures. 1.3 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. 1.4 Demonstrates a thorough understanding of Epic, Outlook, and On-line Eligibility system in order to determine insurance eligibility, initial pre-certifications, and approvals. 1.5 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. 1.6 Alerts the clinician involved in the patient''s care when there are issues with referrals or complications with insurance coverage. 1.7 Obtains all UB-04 information and ensures compliance with health care regulations that govern hospital billing. 1.8 Determines medical necessity of scheduled procedures in accordance with Centers for Medicare & Medicaid Services (CMS) or other payer standards, and communicates coverage/eligibility information to patients. 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 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. 2.3 Ensures that all subsequent follow-up activity is established and adheres to a timely schedule. 2.4 Works with business office staff to understand/trend efforts for authorization-related denials resulting in reduced denials. 2.5 Maintains accurate records of authorizations with the EMR and payer sites. 3. Maintains professional approach at all times when communicating with patients, co-workers, payer representatives and patients 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. 4.1 Identifies and recommends opportunities to improve Patient Access or Financial Clearance activities. 4.2 Keeps abreast of changing federal, state, and insurance regulations and departmental policies/procedures. 4.3 Exhibits a positive attitude as it relates to interaction with coworkers, performance of job responsibilities, and a genuine interest in the proper performance of the job. 4.4 Actively participates in all staff meetings, seminars, training sessions and work groups to advance departmental goals.
High school graduate or GED required with work in healthcare or business preferred. Associate Degree preferred.
One (1) to two (2) years of work experience with insurance authorization/verification of benefits, revenue cycle functions, hospital/physician offices, or related areas required.
Strong organizational skills and ability to prioritize tasks. Strong interpersonal skills and ability to build rapport with a wide variety of individuals. Working knowledge of Microsoft Office, Word, and Excel. Familiarity with medical terminology and healthcare insurance processes. Knowledge of payer reimbursement processes and insurance terminology.
Incumbent is held accountable for the verification of insurance benefits and for determining an acceptable level of coverage for services; the completeness of all required documentation; obtaining of the needed demographic, clinical and financial information to ensure that patients are financially cleared. Notifies patients of liability and collects payment when necessary.
Ability to work and solve problems with minimal oversight. Basic understanding of hospital services to necessary code sets (CPT, HCPCS, ICD-9-CM/PCS, and ICD-10-CM/PCS coding, etc.). Identifies and recommends opportunities to improve Patient Access or Financial Clearance activities.