Financial Clearance Specialist

Job Summary

Processes patient, insurance, and financial clearance activities for both scheduled and non‑scheduled appointments, including validation of insurance coverage and benefits, routine and complex pre‑certifications and prior authorizations, and scheduling and pre‑registration. Responsible for triaging routine financial clearance work.

Primary Responsibilities

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.

• Processes administrative and financial components of financial clearance, including validation of insurance coverage and benefits, medical necessity validation, routine and complex pre‑certification and prior authorization, scheduling and pre‑registration, patient benefit and cost estimates, pre‑collection of out‑of‑pocket cost share, and financial assistance referrals.
• Initiates and tracks referrals, insurance verification, and authorizations for all patient encounters.
• Utilizes third‑party payer websites, real‑time eligibility tools, and telephone communication to retrieve coverage eligibility, authorization requirements, and benefit information, including copays and deductibles.
• Works directly with physician office staff to obtain clinical data required to secure authorization from insurance carriers.
• Inputs information online or contacts carriers to submit authorization requests; provides clinical backup documentation for tests and records approval or pending status.
• Identifies issues and problems within referral and insurance verification processes, analyzes current workflows, and recommends solutions and process improvements.
• Reviews and follows up on pending authorization requests to ensure timely resolution.
• Coordinates and schedules services with providers and clinic staff.
• Researches delays in service delivery and discrepancies in orders.
• Assists management with denial issues by providing supporting documentation and data.
• Pre‑registers patients to obtain demographic and insurance information necessary for registration, insurance verification, authorization, referrals, and billing processes.
• Develops and maintains effective working relationships with interdepartmental personnel, including ancillary departments, physician offices, and financial services.
• Assists Medicare patients with the Lifetime Reserve process, where applicable.
• Reviews prior‑day admissions to ensure timely payer notification for observation status or admission.
• Perform all other duties as assigned.

Education & Experience - Required

• High school diploma or GED.
• Two (2) years of experience in healthcare revenue cycle, medical office, hospital, patient access or related experience.

Education & Experience - Preferred

• Experience in healthcare registration, scheduling, insurance referral and authorization processes.

Knowledge, Skills, & Abilities

• Knowledge of medical and insurance terminology.
• Knowledge of medical insurance plans, particularly managed care plans.
• Ability to understand, interpret, evaluate, and resolve basic customer service issues.
• Excellent verbal communication, telephone etiquette, interviewing, and interpersonal skills required to interact effectively with peers, supervisors, patients, members of the healthcare team, and external agencies.
• Intermediate analytical skills to resolve problems and provide patients and referring physicians with information and assistance related to financial clearance issues.
• Basic working knowledge of the UB‑04 and Explanation of Benefits (EOB).
• Working knowledge of medical terminology and CPT/ICD‑10 coding.
• Demonstrated dependability, critical‑thinking ability, creativity, and problem‑solving skills.
• Knowledge of registration and admitting services, general hospital administrative practices, operational principles, and applicable regulatory requirements, including The Joint Commission and federal, state, and legal statutes, is preferred