Financial Clearance Specialist III - PreArrival - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

University of Southern California•Los Angeles, CA

About The Position

The Financial Clearance Specialist III is responsible for ensuring insurance eligibility, benefit verification, and the authorization processes are complete within the timeframes allowed by insurance companies to prevent denials or penalties. This role involves documenting accurate insurance information and authorization details to optimize reimbursement from both payers and patients. The specialist must maintain a strong working knowledge of insurance plans, contract requirements, and resources to facilitate appropriate insurance verification and authorization. Key duties include running eligibility checks, securing full benefit coverage information (including COBRA when applicable) from insurance companies and employers, confirming demographic information accuracy, and ensuring correct coordination of benefit (COB) and insurance plan codes. The role requires verifying insurance coverage immediately for inpatient and outpatient accounts that are same-day or next-day add-ons. It also involves determining if pre-certification, pre-authorization, or a referral is required by insurance companies and obtaining them if necessary. The specialist will communicate with providers and the team regarding out-of-network issues, assess contracted and non-contracted payer issues, and document outcomes and next steps. Additionally, the role involves determining, communicating, and collecting patient liability prior to service, as well as attempting to collect prior balances. All transactions must be conducted appropriately and consistently, and the Medicare Secondary Questionnaire must be completed accurately with the patient or their representative. Maintaining compliance with HIPAA regulations pertaining to insurance processes is crucial. Professional development is expected through attending workshops, in-services, and webinars to stay updated on insurance rules, regulations, and industry changes. The role is responsible for submitting authorizations for surgery, GI, imaging, chemotherapy, infusions, invasive and non-invasive procedures, transplants, and all other required services.

Requirements

High school or equivalent Or GED required.
2 years Admitting/ insurance verification experience in a hospital, health plan or Physician office environment.
Broad experience in financial counseling and co-pay collections.
Ability to submit authorization and articulate full insurance benefits for Surgery, GI, Imaging, Chemo Therapy, Infusions, and invasive and non- invasive procedures is highly desirable.
The extended ability to perform mathematical calculations, extensive experience in hospital and medical business office setting.
Ability to interrupt patient’s insurance coverage, identify services that are not covered benefit and provide clear explanation to patients and providers.
Strong problem solving customer skills.
Knowledge of business office procedures.
Knowledge of medical terminology and coding.
Knowledge of grammar, spelling, and punctuation to type patient information.
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.
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 reading the policy and procedure manual and understanding information pertaining to specific job duties and the general information for all hospital employees.
Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

Responsibilities

Responsible for obtaining insurance information/verification/authorization to ensure financial clearance of patient accounts.
Updates both professional and / or hospital registration systems.
Ensure all insurance plans are properly selected in all registration and scheduling information systems.
Responsible for calling insurance or use Internet portals to obtain and document: a) Insurance eligibility and benefits, b) Financial responsibility, c) Authorization and / or Pre-Certification as required.
Responsible for understanding and articulating patient’s liability by performing mathematical calculations in understanding out of pocket, co-insurance and deductible calculations.
Responsible for full calculations on all Surgery, GI, Chemo/Infusions, Imaging on non and invasive procedures by following the appropriate documentation standard guidelines.
Responsible for contacting Physician office when a patient’s services are denied, re-directed and or when a Peer to Peer is required.
Communicate with physician offices regarding proposed admissions, special procedures, outpatient referrals and same day surgeries.
Responsible for submitting authorizations for Surgery, GI, Chemo/Infusions, Imaging on non and invasive procedures.
Submits authorizations via the Valor software tool and or websites and follows the appropriate protocol when submitting authorizations.
Responsible for clearing assigned worklists in any of the information systems.
Responsible for completing Documentation of all authorization information is entered in all appropriate registration fields and follows the approved documentation standard guidelines.
Submit pre-certification documentation to third party payers for authorization with correct CPT and ICD coding.
Research payer medical policy requirements for treatment authorizations and understand process for submitting pre-certification requests.
Follow up for routine requests from the message center are followed up on 3-5 business days consistently.
Scan all authorizations into appropriate system under the respective patient accounts and document authorization outcomes in the registration system.
Perform all other duties as assigned.