Financial Clearance Specialist, Outpatient Rehab

Overview

Financial Clearance Specialist, Outpatient Rehab

40 hours per week, day shift

JOB SUMMARY: Assures that insurance eligibility, benefit verification and authorization is completed in the time allowed by the insurance companies to prevent denials or penalties. Documents accurate insurance information and authorization details in order to optimize reimbursement from both the payer and the patient and to prevent potential write offs. Maintains strong working knowledge of insurance plans, contract requirement and resources to facilitate appropriate insurance verification and authorization. 

EDUCATION/EXPERIENCE: High school diploma or GED equivalent and two years' work experience in registration, financial clearance or patient financial services with strong working knowledge of healthcare insurance and benefit programs. Associate's or Bachelor's degree in Health Administration or Business Administration preferred. 

LICENSURE, CERTIFICATION, and/or REGISTRATION: N/A 

ESSENTIAL FUNCTIONS: 

1. Obtains all reports needed to begin insurance verification process that are outside of the Epic work queues. 

2. Confirms eligibility and secures full benefits coverage information, including COBRA when applicable, with insurance companies and employers. 

3. Confirms all demographic information is correct i.e. policyholder's name, date of birth, ID, policy numbers, group name and group number. Assures coordination of Benefits (COBs) and insurance plan codes are accurate. 

4. Verifies Medicare accounts, cross-referencing traditional Medicare and other providers as required. Utilizes all websites and phone as needed. Determines number of prior Medicare days using history from both within and outside our facility. Reviews system to determine if appropriate APC (inpatient versus outpatient) status is correct. Notifies the physician office if the admit status needs to be changed. 

5. Verifies insurance coverage immediately for inpatient and outpatient accounts that are same day and next day add-ons. 

6. Determines if pre-certification, pre-authorization or referral is required by providing ICD-9 and CPT coeds to the insurance company. 

7. Contacts referring physician or other appropriate staff when service is not authorized. Escalates all unauthorized services to management for review and next steps, including delay and reschedule. Communicates with provider regarding out-of-network issues and documents outcomes and next steps. 

8. Calculates, communicates and collects the patient liability prior to service. Conducts all transactions consistent with cash management policies and procedures. Maximizes collection of money by estimating patient liabilities and requesting collection of co-payments and other personal balances prior to or at the time of service. Refers patients to Financial Counselors for assistance as appropriate. 

9. Completes Medicare Secondary Questions accurately with the patient or patient's representative. 

10. Reviews, takes necessary follow up steps and rectifies accounts held due to claim edits to ensure timely submission for billing. 

11. Maintains compliance with HIPAA regulations as it pertains to the insurance process. 

12. Develops and maintains knowledge and skills to identify insurance plans correctly in system, understands contract requirements and maintains accurate insurance information. 

13. Maintains professional development by attending workshops, in-services and webinars to remain up-to-date on insurance rules, regulations in addition to the internal and external changes within the industry. 

14. Performs other duties as assigned. 

SKILLS/QUALIFICATIONS: 

• Excellent knowledge of applicable rules and guidelines governing traditional insurance coverage and reimbursement 
• Excellent interpersonal skills 
• Effective oral and written communication skills 
• Creative problem solving 
• Strong working knowledge of applicable rules, regulations and guidelines governing managed care coverage and reimbursement 

WORK ENVIRONMENT: 

• Clean, comfortable, office environment 
• Work may be stressful at times 
• Contact may involve dealing with angry or upset people
•  Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergencies