Patient Financial Clearance Specialist (104602)

Job Summary (Summary of the basic functions of the position)

The Revenue Cycle Financial Clearance Specialist is a hybrid role supporting the front and back end of the revenue cycle. This position verifies insurance eligibility and benefits, obtains referrals and authorizations, and makes sure patients are financially cleared before their date of service. The specialist also resolves charge and claim edits in NextGen and Availity RCM, helps build and maintain rules in RCx to prevent recurring errors, and supports claim follow-up, denials and payment posting.

The role serves as a liaison between practices, clinics, the business office, payors and patients, and helps reduce rework by tracking edit and denial trends and recommending process improvements. The specialist follows US Dermatology Partners policies and procedures, including those for verification timeliness and out-of-network scheduling, and keeps all patient accounts strictly confidential in line with HIPAA.

Duties and Responsibilities

- Verify that enough information is available for accurate eligibility and benefits verification.

- Use Rivet, Availity, payor portals or direct payor contact to obtain eligibility, benefits, referral and authorization information.

- Determine primary, secondary and tertiary coverage, and set up coordination of benefits (COB), payor and financial class correctly in NextGen.

- Document all verification findings and patient communication in the patient account.

- Enter and review charges accurately and on time in NextGen.

- Work and resolve charge and claim edits in NextGen, including those related to authorizations, demographics, insurance, coding and payor requirements.

- Work and resolve claim edits and rejections in Availity RCM, and resubmit corrected claims promptly.

- Build, test and maintain rules in RCx to automate corrections and prevent recurring charge and claim edits.

- Turn edit, rejection and denial trends into new or updated rules, and monitor how well the rules work after they go live.

- Work with the manager, coding and billing teams to validate rule logic before it is deployed.

- Follow up on unpaid, denied and underpaid claims to resolve them.

- Review EOBs, including Medicare and Medicaid, for accuracy in payment, account information and demographics.

- Review accounts receivable and work outstanding balances and claims.

- Adjust claims paid at out-of-network rates to in-network rates and process the related write-offs.

- Track and report trends in claim edits, denials and repeat tasks to the manager.

- Help optimize workflows by piloting new procedures, applications and policies, and report findings to the manager.

- Follow all safety policies and procedures and support a culture of quality and customer service.

- Perform other duties as needed in the best interest of the organization.

Qualifications

Experience Requirements

- 3+ years in medical insurance verification, patient financial clearance or revenue cycle operations

- 3+ years with PCP referrals and prior authorizations

- 2+ years working claim edits, rejections or denials in a practice management system or clearinghouse

- NextGen, Availity (including Availity RCM), Rivet and RCx experience preferred

- Experience building or maintaining claim scrubber or rules-engine logic preferred