This position is responsible for completing the financial clearance process within Patient Access. This is a higher level position in the FSC that requires understanding of and working with multiple insurance payors to secure benefits and increase the likelihood of reimbursement for Fairview at the highest benefit level.
The Financial Clearance Representative (FCR) must be able to effectively articulate payor information in a manner such that patients, guarantors and family members gain a clear understanding of their financial responsibilities.
The FCR will be responsible for completing the insurance and benefits verification to determine the patient’s benefit level. They will screen payor medical policies to determine if the scheduled procedure meets medical necessity guidelines, submit and manage referral and authorization requests/requirements when necessary, and/or ensure that pre-certification and admissions notification requirements are met per payor guidelines. They will provide support and process prior authorization appeals and denials, when necessary, in conjunction with revenue cycle and clinical staff.
The FCR makes the decision when and how to work with medical staff, nursing, ancillary departments, insurance payors and other external sources to assist families in obtaining healthcare and financial services.
Verifies insurance eligibility. Completes automated insurance eligibility verification, when applicable and appropriately documents information in Fairview’s patient accounting system. Determines the patient’s insurance type and educates patients regarding coverage and/or coverage issues.
Informs families with inadequate insurance coverage regarding financial assistance through government and Fairview financial assistance programs. Performs initial financial screening and refers accounts for financial counseling.
Initiates treatment authorization requests and pursues referrals per payor guidelines. Reviews medical chart/history and physician order(s) to determine likely ICD and CPT codes.
Reviews payor medical policies to determine if procedures meet medical necessity guidelines. Works with clinics and ancillary service departments if medical necessity fails.
Follow up with insurance payors on prior authorization denials. Process authorization denial appeals, when necessary.
HS graduate or diploma
4 years experience working in revenue cycle, insurance verification/eligibility, financial securing or related areas. Experience with practice management software, hospital billing software or electronic health record software.