Patient Financial Clearance Representative

Purpose/Description

The Patient Financial Clearance Representative, under direct supervision of the Revenue Cycle Supervisor, performs specialized functions for CVH patients by completing all activities related to insurance verification, processing referrals and securing appropriate authorization. The Financial Clearance Representative has knowledge of healthcare payers, such as Commercial, Medicare, Medicaid, Workers’ Compensation and all Managed Care plans as well as State and Federal Regulations.

Essential Functions

• Performs pre-registration and financial clearance for multiple patient types (inpatient admissions, outpatient observation, diagnostic outpatients, and ambulatory (day) surgery).
• Completes insurance verification, eligibility and benefit determination process utilizing integrated electronic eligibility system, payer websites, and phone for all insurance plans within the scope of the patient financial clearance department. Interprets and documents the appropriate copay, deductible share of cost, co-insurance, maximum benefits levels and/or available days.
• Develops a strong working knowledge of the procedures and diagnosis used in assigned service-lines to ensure referrals and authorizations are properly completed for the scope of services that will be rendered to the patient.
• Pre-registers the patient for upcoming visit(s), including validating/obtaining and entering demographic, clinical, financial, and insurance information into the patient accounting system.
• Communicates with respective clinics and referring providers to secure appropriate information to complete a referral or authorization.
• Prioritizes work assigned to ensure that financial risk is minimized and timely completion of authorization is completed.
• Identifies risk with securing financial clearance prior to service date and escalates to clinic and other resources to find an appropriate course of action (e.g. reschedule, cancel).
• Understands the role of financial counseling in securing clearance for cases that do not have authorization secured timely. Properly refers these cases as appropriate to management.
• Informs patient/guarantor of their liabilities and collects appropriate patient co-payments, co-insurances, deductibles, deposits and outstanding balances at the point of pre-registration.
• Calculates patient liabilities and provides financial education, referring the patient to resource counseling as required.
• Documents payments/actions in the patient accounting system.
• Validates medical necessity (LMRP/LCD review) of Medicare and Non-Medicare cases to ensure clinical and financial clearance.
• Correctly identify and update various types of insurance.
• Ensures that referrals are addressed in a timely manner.
• Assemble information concerning patient’s clinical background and referral needs.
• Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information, such as history, diagnosis and prognosis.
• Notifies department manager with issues, instances of errors, or obstacles to a successful completion of work.
• Manages inbound and outbound calls.
• May provide assistance to other departmental personnel as needed. Cross-trains in various functions as needed to assist in the smooth delivery of departmental services.

Education and Experience

• Education: Strong verbal and written communication skills. Medical terminology knowledge is recommended. Previous experience required in one or more of the following roles: Minimum (1) year of Hospital or Physician Office Setting, Customer Service, High school Diploma/GED required.
• HFMA Revenue Cycle Certification (may be obtained during the first year of employment).