Minimum Experience/Knowledge: Minimum (3) years of experience in a hospital, health plan or Physician office environment with extensive knowledge of contracted and non-contracted payers, division of financial responsibility, including the ability to articulate benefit negotiations as required when adjudicating a letter of agreement with a non-contracted payer. Proficient in submission of authorization for all service types rendered within a hospital and/or professional setting. Knowledge of business office procedures. Knowledge of medical terminology and coding. Knowledge of grammar, spelling, and punctuation to type patient information. Extended understanding of payer DOFR and authorization submission for all service scopes performed in both a hospital and professional setting Ability to read, understand, and follow oral, and written instructions and establish and maintain effective working relationships with patients, employees, and the public. Excellent time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills. Capable of working assigned shifts, overtime when approved. Capable of reading the policy and procedure manual and understanding information pertaining to specific job duties and the general information for all hospital employees. Must be able to verify insurance and advanced knowledge of both CPT codes and medical terminology. Must also be able to understand and interpret patient liability and benefits for HMOs and all payer types. Proficient in interpreting and completing insurance verification process for all types of payers including HMOâs Commercial, Medi Cal and Senior Plans, Medi Cal, Medicare, PPO, POS, EPO, Capitation, Military, Workman Compensation.
Required License/Certification: Fire and Safety Certification. If no card upon hire, one must be obtained within 30 days of hire, and maintained by renewal before expiration date. The Financial Clearance Specialist IV is responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete. Documentation of accurate insurance information, knowledge of insurance plans and authorization details to optimize reimbursement from the payer are required. The Financial Specialist IV is responsible for extended understanding of division of financial responsibility to accurately adjudicate Letters of agreement to help streamline the claim management process. By securing the mutually signed Letter of agreement provides legal document that outlines the intent of both parties and will provide the supporting documentation needed for appeals for all non-contracted payers for both Professional and Hospital services. The Specialist IV must maintain strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization.Specialist IV must also determine, communicate, and collect patient liability prior to service and attempt to collect prior balances. Specialist IV are to conduct all transactions appropriately and consistently, and complete Medicare Secondary Questionnaire accurately with the patient or patientâs representative. Specialist IV must maintain compliance with HIPAA regulations as it pertains to the insurance processes. Specialist IV must maintain professional development by attending workshops, in-services, and webinars to remain up-to-date on insurance rules and regulations in addition to changes within the industry.Financial Clearance Specialist IV must be proficient in hospital and professional contracted versus non-contract payers including interpretation of language specific to covered services. The specialist must also have an extended understanding of payer DOFR and authorization submission for all service scopes performed in both a hospital and professional setting.
Internal Number: REQ201911143
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