The Financial Clearance Specialist III is responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete in the time allowed by the insurance companies to prevent denials or penalties. Documenting accurate insurance information and authorization details to optimize reimbursement from both the payer and patient. Maintain strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization. Must be able to run eligibility and secure full benefit coverage information (including COBRA when applicable) with insurance companies and employers, confirm all demographic information is correct, and ensure coordination of benefit (COB) and insurance plan codes are accurate. Verify insurance coverage immediately for inpatient and outpatient accounts that are same day and next day add-ons. Determine if pre-certification, pre-authorization or a referral is required for insurance companies and obtain if applicable. Communicate with providers and team regarding out-of-network issues, assess contracted and non-contracted payer issues, and document outcomes and next steps. Determine, communicate, and collect patient liability prior to service and attempt to collect prior balances. Conduct all transactions appropriately and consistently, and complete Medicare Secondary Questionnaire accurately with the patient or patient's representative. Maintain compliance with HIPAA regulations as it pertains to the insurance processes. 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. Responsible in submitting authorizations for surgery, GI , Imaging chemotherapy, Infusions, invasive and non-invasive procedures, transplants, and all other services as required.

Essential Duties:

• Responsible for obtaining insurance information/verification/authorization to ensure financial clearance of patient accounts. Updates both professional and / or hospital registration systems. Ensure all insurance plans are properly selected in all registration and scheduling information systems. 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. (20%)
• Responsible for understanding and articulating patient's liability by performing mathematical calculations in understanding out of pocket, co-insurance and deductible calculations. Responsible for full calculations on all Surgery, GI, Chemo/Infusions, Imaging on non and invasive procedures by following the appropriate documentation standard guidelines. (20%)
• Responsible for contacting Physician office when a patient's services are denied, re-directed and or when a Peer to Peer is required. Communicate with physician offices regarding proposed admissions, special procedures, outpatient referrals and same day surgeries. (20%)
• Responsible for submitting authorizations for Surgery, GI, Chemo/Infusions, Imaging on non and invasive procedures. Submits authorizations via the Valor software tool and or websites and follows the appropriate protocol when submitting authorizations. Responsible for clearing assigned worklists in any of the information systems (15%)
• Responsible for completing Documentation of all authorization information is entered in all appropriate registration fields and follows the approved documentation standard guidelines. Submit pre-certification documentation to third party payers for authorization with correct CPT and ICD coding. Research payer medical policy requirements for treatment authorizations and understand process for submitting pre-certification requests. Follow up for routine requests from the message center are followed up on 3-5 business days consistently. Scan all authorizations into appropriate system under the respective patient accounts and document authorization outcomes in the registration system. (15%)
• Perform all other duties as assigned. (10%)

Required Qualifications:

• Req High school or equivalent Or GED required.

• Req 2 years Admitting/ insurance verification experience in a hospital, health plan or Physician office environment.
• Req Broad experience in financial counseling and co-pay collections.

• Req Ability to submit authorization and articulate full insurance benefits for Surgery, GI, Imaging, Chemo Therapy, Infusions, and invasive and non- invasive procedures is highly desirable.
• Req The extended ability to perform mathematical calculations, extensive experience in hospital and medical business office setting.
• Req Ability to interrupt patient's insurance coverage, identify services that are not covered benefit and provide clear explanation to patients and providers.
• Req Strong problem solving customer skills.
• Req Knowledge of business office procedures.
• Req Knowledge of medical terminology and coding.
• Req Knowledge of grammar, spelling, and punctuation to type patient information.
• Req Must be able to verify insurance and advanced knowledge of both CPT codes and medical terminology.
• Req Must also be able to understand and interpret patient liability and benefits for HMOs and all payer types.
• Req Ability to read, understand, and follow oral, and written instructions and establish and maintain effective working relationships with patients, employees, and the public.
• Req Excellent time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills.
• Req Capable of reading the policy and procedure manual and understanding information pertaining to specific job duties and the general information for all hospital employees.

Preferred Qualifications:

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)