Clinical Financial Specialist. JOB CODE:30460 FLSA Exemption Status:Non-Exempt. SUMMARY (BASIC PURPOSE OF THE JOB)Oversees the accurate and timely verification of authorizations, referrals, charge capture and clinical documentation to ensure optimal reimbursement. Responsible for the overall supply ordering and inventory management, in assigned clinical area. Educates and works collaboratively with physician offices, clinical team members, and management to ensure effective and efficient utiliza... more details
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Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.
Position Overview:
Clinical Financial Specialist
JOB CODE:30460
FLSA Exemption Status:Non-Exempt
SUMMARY (BASIC PURPOSE OF THE JOB)
Oversees the accurate and timely verification of authorizations, referrals, charge capture and clinical documentation to ensure optimal reimbursement. Responsible for the overall supply ordering and inventory management, in assigned clinical area. Educates and works collaboratively with physician offices, clinical team members, and management to ensure effective and efficient utilization of resources. Performs ongoing assessment of the integrity of charge capture processes and reports problems/issues with suggested action plan or options to the Director.
MINIMUM REQUIREMENTS
Education:High school diploma. Certification or license in surgical or diagnostic procedures, licensed registered nurse, or LPN. Associate's degree preferred.
Experience:Five years experience in an acute care procedural/diagnostic setting. Understanding of ICD-10/CPT codes and pre-certification preferred.
Other Credentials:
Knowledge and Skills:Excellent verbal and written communication skills, solid organization, and follow-up skills. Strong interpersonal skills and the ability to manage multiple tasks simultaneously.
Special Training:Proficiency in Microsoft Office (Word, Excel, and Outlook). Strong knowledge and experience of medical/clinical terminology.
Mental, Behavioral and Emotional Abilities:Ability to change priorities when necessary and meet deadlines. Demonstrates good judgment as well as attention to detail.
Usual Work Day:8 Hours
ESSENTIAL FUNCTIONS
- Verifies pre-certification and authorizations from various insurance carriers to facilitate maximum utilization, efficiency, and minimal procedure-related problems. Verifies referrals and pre-certifications for patients according to insurance requirements, twenty-four hours before date of service.
- Obtains, and advises patients of, all necessary pre-certification and referrals needed for financial reimbursement. Gathers complete authorization and referral information and scans the information into the imaging database.
- Understands and utilizes the necessary software program to determine "medical necessity" prior to scheduling a patient.
- Following completion of procedure, verifies procedure was performed, as ordered. If additional/modified procedures are completed, obtain authorization for revised codes as needed according to insurance requirements.
- Works in conjunction with physician(s) and Director/Manager to develop a rapport with the referring offices and work collaboratively to obtain appropriate documentation for procedures.
- Ensures proper matching of revenue codes, HCPCS codes, CPT-4 codes and charge description items to procedures performed. Ensures completeness of charge capture following the case and works with clinical team when missing or incorrect charges are identified.
- Troubleshoots any issues related to the financial integrity and accuracy of the documentation and/or insurance requirements of the account, and resolves these issues with the internal departments and external offices.
- Acts as the clinical and financial liaison between Capital Health and any payer/third party who audits CH patient accounts.
- Identifies any new supplies, devices or tests that would warrant the creation of a new Charge Description Master (CDM). Works collaboratively with the Charge Master Analyst, as well as the department, to update and maintain Capital Health's Charge Master.
- Reviews charge sheets and related forms with clinical staff and communicate to department leadership any missed revenue opportunities. Facilitates change processes required to capture needed documentations, such as forms redesign.
- Educates the clinical staff, medical staff providers, and financial members of Capital Health about clinical documentation, charge capture, and related procedure codes. Educates referring physician office staff about appropriate authorization and ICD-10 code assignment.
- Reviews and clarifies clinical and non-clinical issues in the health record with the coding professionals and patient access/central scheduling support staff.
- Maintains supply inventory, reorders supplies to maintain appropriate par levels, and works with surgical value analysis team to identify any new product needs, if applicable. Works collaboratively with supply chain staff and vendors to order new and existing products.
- Maintains a level of expertise by attending continuing education programs.
PHYSICAL DEMANDS AND WORK ENVIRONMENT
Frequent physical demands include:
Occasional physical demands include: Standing , Walking , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation
Continuous physical demands include: Sitting , Pinching/fine motor activities , Keyboard use/repetitive motion , Talk or Hear
Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.
Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Depth Perception, Accurate Hearing
Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Airborne Communicable Disease , Extreme Noise Levels , Dust/Particulate Matter
Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.
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