The Financial Clearance Specialist reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Consistently practices Patients First philosophy and adheres to high standards of customer service. This includes setting an example to peers, coworkers, etc. by fostering a team atmosphere.
- Responds to questions and concerns.
- Forwards, directs and notifies Team Lead or Operations Coordinator of extraordinary issues as necessary.
- Maintains patient confidentiality per HIPAA regulations.
- Provides exceptional customer service to consumers which establish a positive first impression of Northwestern Medicine.
- Exceeds all consumer requests and alerts management of issues or concerns that require escalation.
- Correctly identifies and collects patient demographic information in accordance with organization standards.
- Responds to telephone inquiries and performs appropriate action(s).
- Documents all actions taken in the appropriate software applications.
- Monitors admission/registration and scheduled surgeries flow of patient information through the revenue cycle.
- Serves as a resource to staff and patients for insurance related issues.
- Has a strong understanding of Medicare/Medicaid rules and regulations, and managed care products.
- Is knowledgeable of current contracted and non-contracted healthcare insurance plans.
- Reviews patient electronic medical record for appropriate diagnosis and pre-treatment rendered.
- Has thorough understanding and working knowledge of CPT and ICD-10 coding.
- Consults with physicians and their assistants whenever questions arise to insure timely approvals.
- Follows through and makes corrections in demographics and insurances as they are discovered.
- Data entry accuracy is imperative in this position.
- Monitors Referral In-Basket in EPIC to insure work is consistently completed in a timely manner.
- This involves watching for future test requests to come due and then pre-authorized within the time frame specified by the insurance carrier and the patient notified.
- Facilitates the pre-authorization of diagnostic exams, between referring physicians and insurance carriers, through the use of online tools, work lists, and direct phone calls as necessary to ensure maximized patient benefits.
- Ensures all admissions, scheduled surgeries, and certain outpatient procedures are financially cleared, to allow for maximum and timely reimbursement to the hospital.
- Interacts with various hospital departments and physicians offices to effectively schedule and direct patients through the NMHC systems in a patient/customer friendly manner.
- Performs medical necessity checks as necessary for scheduled services, communicates options to patient if appointment fails.
- Informs patients of any issues with securing the financial account for their encounter and completes out-of-pocket estimations as requested by patients.
- Provides training and education as needed.
- Manages work schedule efficiently, completing tasks and assignments on time.
- Participates in Quality Assurance reviews to insure integrity of patient data information.
- Uses effective service recovery skills to solve problems or service breakdowns when they occur.
- Utilizes department and hospital policies and procedures to complete assigned tasks.
- Performs duties within the regulatory guidelines of the Fair Patient Billing Act and the Fair Debt Collection Act.
- Other duties as assigned.
- Communication and Collaboration:
- Communicates information to the patient regarding questions about physician referrals, insurance referrals and consultations.
- Collects authorization numbers in appropriate systems as applicable.
- Provides professional and constructive environment for communication across units/departments and resolves operational issues.
- May attend intra/interdepartmental meetings which involve walking within NM Campus.
- Communicates customer satisfaction issues to appropriate individuals.
- Demonstrates teamwork by helping co-workers within and across departments.
- Communicates effectively with others, respects diverse opinions and styles, and acknowledges the assistance and contributions of others.
- Ensures that outpatient procedures have a valid diagnosis code, and that for Medicare patients, medical necessity has been met.
- Communicates with physician offices to troubleshoot failing medical necessity for Medicare patients.
- Contacts patients to notify them of high out-of-pocket liabilities, and to establish/enforce compliance with hospital financial policies.
- Reviews and analyzes all required demographic, insurance/financial and clinical data procured by patient intake and registration areas necessary to expedite payment on patient accounts.
- Verifies eligibility and benefit information using on-line programs.
- Performs pre-certification notification via telephone or electronically and gathers and completes all required documentation for submission to insurance carriers per payor requirements.
- Participate in researching pre-certification denials including missing authorization, patient pre-certification or referral documentation.
- Works on denied accounts with ancillary departments, physician and account representatives to gather required information.
- Cross-training between various departments may take place to insure coverage.
- Technology:
- Utilizes multiple online order retrieval systems to verify or print the patients order.
- Verifies insurance eligibility and benefit levels through the use of online tools (NDAS, ASF, etc.) or over the phone as necessary.
- Completes accurate handoff instructions and notes to scheduling staff, by noting appropriately in Epic.
- Demonstrates ability to use all computer applications efficiently and to the capacity needed in this position.
- Efficiency, Process Improvement, and Business Growth:
- Proactive in preventing issues with patient visit by double checking type of test, preps required, assuring no conflict with other tests, verifying time and location, communicating relevant information and documenting order retrieval in notes for check-in person.
- Understands minimum data set required for a complete registration, collects and verifies critical data and updates that information into registration system.
- Understands departmental and individual quality metrics.
- Proactively analyzes account activity, identifies problems, and initiates appropriate actions/resolutions.
- Evaluates procedures and suggests improvements to enhance customer service and operational efficiency.
- Participates in departmental quality improvement activities.
- Provides ideas and suggestions for process improvements within the department.
- Monitors registration and scheduling, including insurance verification to insure processing within prescribed quality standards.
- Adjusts processes as needed to meet standards.
- Uses organizational and unit/department resources efficiently.
- Acts as a training resource for new staff and a resource for coworkers, sharing process and workflow information.
AA/EOE