Financial Clearance Specialist IV - Prearrival - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

The Financial Clearance Specialist IV is responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete. Documentation of accurate insurance information, knowledge of insurance plans and authorization details to optimize reimbursement from the payer are required. The Financial Specialist IV is responsible for extended understanding of division of financial responsibility to accurately adjudicate Letters of agreement to help streamline the claim management process. By securing the mutually signed Letter of agreement provides legal document that outlines the intent of both parties and will provide the supporting documentation needed for appeals for all non-contracted payers for both Professional and Hospital services. The Specialist IV must maintain strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization. Specialist IV must also determine, communicate, and collect patient liability prior to service and attempt to collect prior balances. Specialist IV are to conduct all transactions appropriately and consistently, and complete Medicare Secondary Questionnaire accurately with the patient or patient's representative. Specialist IV must maintain compliance with HIPAA regulations as it pertains to the insurance processes. Specialist IV 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 IV must be proficient in hospital and professional contracted versus non-contract payers including interpretation of language specific to covered services. The specialist must also have an extended understanding of payer DOFR and authorization submission for all service scopes performed in both a hospital and professional setting.

Essential Duties:

• Responsible for obtaining insurance information/verification/authorization to ensure financial clearance of patient accounts. Updates hospital registration systems. • Submits authorization and secures Pre Cert as appropriate for all services rendered to non-contracted patients. • Interprets and completes insurance verification process for all types of payers including HMO’s Commercial, Medi Cal and Senior Plans, Medi Cal, Medicare, PPO, POS, EPO, Capitation, Military, Workman Compensation • Confirms that benefits are aligned with appropriate plan code selected in registration systems assuring clean claim. • Follow up for routine requests from the message center are followed up on 3-5 business days consistently
• Completion and Submission of Letter of Agreements to all Professional and Hospital Non Contracted Payers. • Responsible for verifying each new encounter specific to DOFR to ensure appropriate letter of agreement is secured. • Entry of all communications from Payers and or Physician offices is documented in the registration system as stated in the documentation standard guidelines and Letters of agreement are scanned into Medical Records system as appropriate.
• Responsible for calling insurance or use Internet portals to obtain and document: a) Insurance eligibility and benefits, b) Financial responsibility, c) Authorization and / or Pre-Certification as required. • Submit authorizations via the Valor software tool and or websites and follows the appropriate protocol when submitting authorizations.
• Responsible for contacting Physician office when a patient’s services are denied, re-directed and or when a Peer to Peer is required. • Research payer medical policy requirements for treatment authorizations and understand process for submitting pre-certification requests.
• Documentation of all authorization information is entered in all appropriate registration fields and follows the approved documentation standard guidelines. • Responsible for accurate submission of CPT and ICD 10 coding to at risk payer(s) for authorization. • Research payer medical policy requirements for treatment authorizations and understand process for submitting pre-certification requests. • Scan all authorizations into appropriate system under the respective patient accounts and document authorization outcomes in the registration system.
• Perform all other duties as assigned.

Required Qualifications:

• Req High school or equivalent Or GED required.

• Req 3 years Experience in a hospital, health plan or Physician office environment

• Req Extensive knowledge of contracted and non-contracted payers, division of financial responsibility.
• Req Ability to articulate benefit negotiations as required when adjudicating a letter of agreement with a non-contracted payer.
• Req Proficient in submission of authorization for all service types rendered within a hospit