POSITION SUMMARY:
The Financial Clearance Specialist is the core clearance function of the Financial Clearance Center (FCC). This role reviews assigned referrals to identify patient insurance eligibility and benefits, determine coverage classification, and confirm medical necessity and authorization requirements. The Financial Clearance Specialist builds patient estimates and initiates, tracks, and validates prior authorizations across commercial, Medicare, Medicare Advantage, and other payer types, ensuring each account is appropriately cleared before scheduling and date of service.
SUPERVISION: Reports to the Financial Clearance Center Director.
RESPONSIBILITIES AND DUTIES:
- Review incoming referrals to confirm insurance coverage, network status, and whether a service requires prior authorization.
- Screens referrals for medical necessity and coverage concerns, working directly with referring provider’s office to resolve questions or request additional documentation.
- Identifies patient insurance eligibility, benefits and prepares a clear cost estimate. Ability to review information directly with patient by phone, answer coverage and estimated patient financial responsibility questions.
- Submits, tracks, and confirms prior authorizations with commercial insurance, Medicare, and Medicare Advantage plans.
- Research and document claims involving workers' compensation, motor vehicle accidents (MVA), and Veterans Affairs (VA) coverage, applying the distinct authorization and billing requirements for each.
- Determines the correct order of coverage when a patient has more than one active insurance plan.
- Updates authorizations when a scheduled procedure's scope changes.
- Ability to collaborate with others to resolve last-minute insurance changes before a patient's appointment.
- Ability to work through complex or unclear coverage situations to department leadership for guidance.
- Maintains clear, accurate documentation of all clearance activity.
- Performs other duties as assigned.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
EDUCATION AND WORK EXPERIENCE
- High school diploma required; Associate degree in a healthcare-related or business-administration field preferred. Minimum of two years of directly related experience in financial clearance, insurance verification, prior authorization, medical necessity review, or eligibility determination required.
- Demonstrated hands-on experience initiating, validating, and documenting prior authorizations.
- Demonstrated working knowledge of medical necessity criteria, insurance coverage types, and eligibility verification.
- Working knowledge of CPT/HCPCS and ICD-10 coding and medical terminology, with the ability to distinguish non-covered and excluded services from other coverage determinations.
- Working knowledge of Medicare coverage criteria and commercial payer medical policy.
- Experience with Epic or a comparable EMR, including referral, authorization, and eligibility workflows, preferred.
SKILLS AND ABILITIES
- Strong verbal and written communication skills, with the demonstrated ability to interact professionally with patients, visitors, physicians, department staff, and coworkers; team-oriented with strong interpersonal skills.
- Able to function effectively in a fast-paced environment, applying strong quantitative, analytical, and problem-solving skills with excellent attention to detail and organization.
- Demonstrates composure and sound judgment under pressure; adaptable to change, decisive, and able to anticipate issues before they escalate; shows strong organizational and leadership capability.
- Maintains thorough, accurate, and organized documentation of all clearance activity, ensuring the work is clearly understood by anyone reviewing the account later.
- Proficient in Microsoft Office, Epic, or comparable EMR and work queue systems, with the ability to learn new software applications as introduced.
Physical Demands/Work Environment
- Must have considerable hand-eye coordination to operate a computer.
- Must be able to sit or stand for long periods of time.
- Must be able to exchange accurate information with patients, family, peers, and medical personnel through both verbal and written communication.
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.