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 Analyst is responsible for the financial clearance of complex patient authorizations, including insurance verification, price estimation, and validation of medical necessity for services. In addition, is accountable for coordinating the activities of the patient account from the point of scheduling through account clearance. Formulates solutions to respond and resolve non-clinical customer requests, issues and problems, while meeting the changing demands and priorities in a hospital environment. Works closely with the patients, families, outside departments and third party payers to ensure compliance to all authorization and medical necessity guidelines in order to protect the patient and the Hospital from unnecessary financial loss.
Responsibilities: 1. Collects, validates and accurately documents patient insurance and benefits information and is fully knowledgeable about all aspects of insurance verification requirements. 1.1. Utilizes the On-line Eligibility system and/or other means (i.e. telephone, fax or various third party payer website) to obtain insurance benefits and makes sure insurance verification information is accurate and inputs the information into Epic. When necessary, alerts the appropriate staff of insufficient and/or termination of benefits. 1.2. Demonstrates a thorough understanding of Epic, Outlook, and On-line Eligibility system in order to determine insurance eligibility, initial pre-certifications, and approvals. 1.3. 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. 1.4. Alerts the clinician involved in the patient's care when there are issues with referrals or complications with insurance coverage. 1.5. Obtains all UB-04 information and ensures compliance with health care regulations that govern hospital billing. 1.6. Possesses good working knowledge of medical necessity rules to determine if the scheduled procedures is 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. Reads and comprehends the medical record to help identify pertinent information to obtain necessary authorization. Must be able to communicate complex clinical information to necessary parties. 2.3. 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. 2.4. Possesses a working knowledge of hospital services, diagnostic testing and code sets (CPT, HCPCS, ICD-10-CM/PCS coding, etc.). 2.5. Contributes to the financial vitality of the organization by thoroughly understanding key operational dependencies (insurance eligibility, referral, authorizations, etc.) and verifies eligibility as outlined in departmental procedures. 2.6. Educates patients and clinicians about the authorization process as well as medical necessity rules, local coverage determination policies and any other payer-specific guidelines. 2.7. Ensures that all subsequent follow-up activity is established and adheres to a timely schedule. 2.8. Works with business office staff to understand/trend efforts for authorization-related denials resulting in reduced denials. 2.9. 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. Enhances the overall patient care experience through efficient work processes and communication of delays, proactively meeting the patient needs. 3.2. Collaborates with departments and co-workers to enhance physician and patient satisfaction by utilizing available technologies to streamline verification and financial processes, reduce redundancy of information requested and monitor insurance verification issue/opportunities with third party payers, and provides feedback to Supervisor for implementation of process improvement. 3.3. Contacts patients as needed to gather demographic and insurance information, and updates patient information within the EMR as necessary. 3.4. Informs the patient whether the authorization for the referral has not been approved. 3.5. Calculates and provides patient liability estimate and educates patient on their insurance benefits as necessary. 3.6. Requests pre-service payment for patient liability and/or arranges payment plans using appropriate guidelines. 3.7. 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. Participates in ongoing quality improvement efforts of the department, utilizing good problem solving methods and resourcefulness to address and resolve problems or to refer them to the appropriate person or department for resolution. 4.2. Identifies and recommends opportunities to improve Patient Access or Financial Clearance activities. 4.3. Keeps abreast of changing federal, state, and insurance regulations and departmental policies/procedures. 4.4. Presents facts in a logical pattern and completes summaries to be presented to upper management. 4.5. Exhibits a positive attitude as it relates to interaction with co-workers, performance of job responsibilities, and a genuine interest in the proper performance of the job. 4.6. Actively participates in all staff meetings, seminars, training sessions and work groups to advance departmental goals. 4.7. Maintains CRCS or equivalent certification for Access Professionals.
High school graduate or GED required with work in healthcare or business preferred. Associate Degree preferred. CRCS or equivalent certification for Access Professionals required or in process (within an 18 months of hire).
Two (2) to three (3) years of work experience with insurance authorization/verification of benefits, revenue cycle functions, hospital/physician offices, or related areas required.
CRCS or equivalent certification for Access Professionals required or in process (within an 18 months of hire).
Strong organizational skills and ability to prioritize tasks. Strong interpersonal skills and ability to build rapport with a wide variety of individuals. Knowledge of payer reimbursement processes and insurance terminology. Basic understanding of diagnostic testing and procedure codes (CPT, HCPCS, ICD-9-CM/PCS, and ICD-10-CM/PCS coding, etc.). Excellent verbal and written communication skills including the ability to communicate with physician providers. Intermediate working knowledge/understanding of medical terminology and disease process. Expert knowledge of Microsoft Office, Word, and Excel.
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 present facts in a logical pattern and completes summaries to be presented to upper management. Ability to identify and solve problems independently. Working knowledge 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