Financial Clearance Analyst

Yale New Haven Health•New Haven, CT

About The Position

The Financial Clearance Analyst is responsible for financial clearance for complex patient authorizations, including insurance verification, price estimation, and validation of medical necessity. The role coordinates patient account activities from scheduling through account clearance and develops solutions to resolve non-clinical customer requests, issues, and problems in a changing hospital environment. The analyst works with patients, families, other departments, clinicians, and third-party payers to ensure compliance with authorization and medical necessity guidelines and help protect patients and the hospital from unnecessary financial loss. The position collects and verifies insurance and benefits information, obtains pre-certifications and prior authorizations, assesses medical necessity, maintains accurate authorization records, and communicates coverage, eligibility, and patient liability information. It also supports timely follow-up, helps address authorization-related denials, contributes to quality and process improvement, and maintains CRCS or an equivalent Access Professionals certification.

Requirements

High school diploma or GED required.
CRCS or equivalent certification for Access Professionals required or must be in process within 18 months of hire.
Strong organizational skills and ability to prioritize tasks.
Strong interpersonal skills and ability to build rapport with a wide variety of individuals.
Knowledge of payer reimbursement processes and insurance terminology.
Basic understanding of diagnostic testing and procedure codes, including CPT, HCPCS, ICD-9-CM/PCS, and ICD-10-CM/PCS.
Excellent verbal and written communication skills, including the ability to communicate with physician providers.
Intermediate working knowledge of medical terminology and disease processes.
Expert knowledge of Microsoft Office, Word, and Excel.

Nice To Haves

Healthcare or business-related work preferred.
Associate degree preferred.
Two to three years of work experience in insurance authorization or benefits verification, revenue cycle functions, hospital or physician offices, or related areas preferred.

Responsibilities

Collect, validate, and accurately document patient insurance and benefits information.
Use online eligibility systems, telephone, fax, and payer websites to verify benefits; enter accurate information in Epic and alert appropriate staff to insufficient or terminated benefits.
Use Epic, Outlook, and online eligibility systems to determine insurance eligibility and obtain initial pre-certifications and approvals.
Complete pre-certification notices before admission and initiate notification to insurers within 24–48 hours of emergency admissions, escalating unresolved issues to management as needed.
Alert clinicians to referral issues or complications with insurance coverage.
Obtain UB-04 information and ensure compliance with healthcare regulations governing hospital billing.
Apply medical necessity rules and payer standards, including CMS standards, and communicate coverage and eligibility information to patients.
Obtain prior authorizations from third-party payers according to payer requirements.
Use Epic applications to obtain procedure codes as needed.
Review medical records to identify information needed for authorization and communicate complex clinical information to relevant parties.
Provide information to third parties to determine benefits and obtain approvals and authorizations needed for billing and payment.
Verify eligibility and understand operational dependencies such as referrals and authorizations.
Educate patients and clinicians about authorization processes, medical necessity rules, local coverage determination policies, and payer-specific guidelines.
Establish and complete follow-up activity on a timely schedule.
Work with business office staff to understand and track authorization-related denials and help reduce them.
Maintain accurate authorization records in the EMR and payer sites.
Communicate professionally with patients, coworkers, and payer representatives.
Support a positive patient-care experience through efficient processes and communication about delays; proactively address patient needs.
Collaborate with departments and coworkers to improve physician and patient satisfaction, streamline verification and financial processes, reduce redundant information requests, monitor payer issues and opportunities, and provide process-improvement feedback to the Supervisor.
Contact patients to gather demographic and insurance information and update patient records in the EMR as needed.
Inform patients when referral authorization has not been approved.
Calculate and provide patient-liability estimates and explain insurance benefits as needed.
Request pre-service payment for patient liability or arrange payment plans under applicable guidelines.
Identify situations requiring service recovery, take corrective action, and follow through to prevent recurrence.
Perform other duties assigned by the Supervisor.
Participate in departmental quality-improvement efforts, using problem-solving methods and resourcefulness to resolve or appropriately refer issues.
Identify and recommend improvements to Patient Access or Financial Clearance activities.
Keep current with federal, state, and insurance regulations and departmental policies and procedures.
Present facts logically and prepare summaries for upper management.
Maintain a positive attitude and genuine interest in performing the job properly.
Participate in staff meetings, seminars, training sessions, and work groups to advance departmental goals.
Maintain CRCS or an equivalent certification for Access Professionals.