Authorization & Clearance Specialist, Full Time

About the Role

The Financial Clearance Center (FCC) Authorization & Clearance Specialist ensures medical services provided to patients are covered by their insurance providers. This role involves obtaining pre-authorizations, verifying insurance coverage, managing authorizations, and coordinating financial responsibilities.

Responsibilities

• Identifies and confirms valid insurance coverage for episodes of care or specific services by contacting insurance companies or reviewing electronic responses.
• Initiates, follows up on, and validates authorizations, referrals, or notifications with appropriate CPT, ICD-10 codes, Tax ID, and NPI numbers within required timelines.
• Manages daily work queues to prioritize patients requiring authorization based on appointment schedules, medical severity, payer assignments, and dollar value.
• Verifies covered benefits, validates benefit package restrictions, and performs quality assurance checks on authorization details (e.g., patient type, facility).
• Understands patient deductibles, out-of-network referrals, out-of-pocket limitations, and lifetime/event caps on liability.
• Refers patients to Financial Counselors, Prior Authorization, or Billing teams based on financial coverage, employment status, or liability concerns.
• Uses insurance discovery tools to validate coverage and ensure correct coordination of benefits on patient records; follows up with patients or care teams to obtain missing information.
• Obtains pre-certification/authorization for services and notifies patients and referring physicians of eligibility or authorization issues.
• Follows up with clinical teams, physicians, or Case Management for pending clinical documentation, including peer-to-peer requests.
• Ensures timely processing of authorizations with insurance payers and escalates as needed.
• Collaborates with JHS medical services to ensure procedures, diagnoses, and levels of care meet CMS and payer guidelines.
• Maintains knowledge of JHS Charity and Financial Assistance programs, including qualification requirements and processes for Charity Care clearance.
• Calculates patients' financial responsibility using estimator tools and communicates out-of-pocket costs to patients.
• Coordinates Self-pay Package pricing using available tools and escalates to the Managed Care team for complex contracts or unlisted prices.
• Processes patient payments in accordance with JHS Collections Policy, issues receipts, and maintains payment integrity.
• Scans and uploads required documents into the documenting imaging system to ensure compliance and maximum reimbursement.
• Supports system go-lives, department initiatives, and team member onboarding/training.
• Cross-trained in multiple areas, service lines, or payers to substitute for staff as needed.
• Demonstrates service excellence and CARE values (Compassion, Accountability, Respect, and Expertise).
• Performs other related duties as assigned.

Requirements

• 0 to 3 years of related experience; financial clearance experience strongly preferred.
• High school diploma required; Bachelor's degree in a related field strongly preferred.
• Valid license or certification as required by the job or specialty.

Skills

• Ability to analyze, organize, and prioritize work accurately while meeting multiple deadlines.
• Effective oral and written communication skills.
• Professional composure and critical thinking in difficult or stressful situations.
• Ability to understand and follow instructions and exercise independent judgment.
• Proficiency in job-appropriate technology and software applications.

Working Conditions

• Physical Requirements: Sedentary role requiring extended sitting; frequent standing or walking. Must lift or carry objects up to 20 pounds. Requires close visual acuity for computer use, data analysis, and office tasks.
• Environmental Conditions: Fast-paced environment with occasional high-pressure or emergent situations. Frequent interaction with diverse populations (team members, providers, patients, insurance companies, and the public). Subject to inside environmental conditions with occasional outdoor exposures. Possible exposure to communicable diseases, toxic substances, or medicinal preparations common in hospital/medical office settings. May require Personal Protective Equipment (PPE) such as gloves or masks.

Reasonable accommodations are available for individuals with disabilities to perform essential functions.