Manager of Financial Clearance is the direct point of contact for all financial clearance needs from insurance verification to patient cost inquiries/education within the CHOP Organization, supporting both Hospital and Physician Practice Plans. Manager of Financial Clearance partners with leadership and other internal and external customers to ensure timely completion of authorizations and to ensure effectiveness of the precertification / authorization process. Oversee processes to aid in proper reimbursement and manage administrative denials in accordance with payor contracts and maximize the financial reimbursement for the hospital.
This position is responsible for overseeing the financial clearance team including insurance verification, price estimation, and validation of medical necessity for certain services. Manager will ensure peak performance of the Financial Clearance area assuring patients and internal staff obtain access to authorizations and price inquiries in a professional and family friendly atmosphere. The Manager will ensure the team provides consistent financial experience for patients and families from verification of benefits through authorizations and estimates to enable patients/families and other care purchasers to choose CHOP as their valued provider.
This individual will have extensive knowledge of the organization’s charge masters, payor contracts, referral and authorization standards, and an ability to analyze and communicate information surrounding patient and family financial responsibility for services, including applicable discounts, in a professional and polite atmosphere. Manager will be required to have a detailed understanding of price transparency within the industry and how it relates to CHOP Strategy. Estimates will include price shopping in comparison to competing health systems, international patient price estimates, retail price estimates, cutting edge price estimates, US-Domestic self-pay patients, and insured patient responsibility for the covered amount contractually allowed.
Manager will utilize analytics data to achieve quality metrics and support operational enhancements for the Financial Clearance team. Manager is responsible for communication and training of staff in an effort to standardize CHOP’s financial clearance process. This role is responsible for maintaining organizational awareness of new policies involving price transparency and identifying strategies to ensure the organization remains compliant with ongoing transparency requirements
- Oversight and implementation of Financial Clearance team, including staffing operational processes, developing annual and multi-year work plans and strategies, ensuring resources are available to achieve work plans, resolving complex business issues, and establishing management practices.
- Works closely with organizational leaders to implement new processes and training while maintaining productivity and minimizing disruption financial clearance workflows
- Completes financial analyses and projections that correspond to CHOP’s revenue cycle key performance indicators
- Monitors facility progress based on performance benchmarks and addresses issues as they arise; identifies and quantifies mid-cycle revenue leakage and works with facility leadership to implement solutions.
- Participates with Corporate Managed Care to review contracting relationships, operational impediments, and reimbursement scenario analysis connected with relative coverage areas.
- Clear understanding of multiple types of reimbursement models, as well as changing models such as bundles, value based, shared savings, and how they relate to patient financial responsibility.
- Financially secure patient care prior to or at time of care, avoid bad debt related to inaccurate patient cost estimates as a result of incorrect patient payer or demographic data, and enhance patient/family and physician/provider satisfaction with patient cost estimation processes.
- Ensures that financial clearance processes align with CHOP’s strategic initiatives with emphasis on transparency and the overall patient and family financial experience.
- Monitors metrics and develops performance improvement plans to improve patient and provider/staff interactions and experiences.
- Trends and reports financial clearance metrics by type, payor, service, etc.; publish summary report monthly to all Business Office Directors.
- Provides routine alignment of strategy and tactics within the Department to achieve success through the development of metrics and monitor/communication of success against them.
- Establishes partnerships with PARC Support, HB, and PB peers to ensure new services are identified and included in pricing tool.
- Provides on-going communication and partnership with Revenue Cycle departments and all divisions
- Supports enterprise wide financial clearance processes and workflows from benefit verification through authorizations
- Replies to inquiries for price estimates and prepare estimates of amounts due based on anticipated services and type of estimate requested (i.e. charges, reimbursement, patient responsibility, etc.).
- Accepts payments made in advance of service and hands off to appropriate billing office for posting to patient account.
- For patient/families with insurance, calculates patient estimate based on plan, benefits and out of pocket thresholds; discusses and finalizes method of payment. Ensures all activities are documented within EPIC. Ensures all completed estimates are issued in letter format.
- Establishes written policies and procedures governing operational workflow.
- Maintains sound working knowledge of current industry best practice concepts and practices, and is responsible for the integration and adoption of best practice processes.
- Develops written policies and procedures based on best practices within the industry.
- Proactively identifies and resolves operational and system problems or issues.
- Recommends enhancements to the current workflow that will help to streamline the operation and provide greater service to customers.
- Identifies system interface delays. Prepares specifications for system improvements and work with Information Systems, Sr. Systems Analysts, and other pertinent parties to resolve problems.
Required Licenses, Certifications, Registrations
Required Education and Experience
Required Education: Bachelor’s degree
Required Experience: At least seven (7) years of experience in customer service, revenue cycle or operations with a working knowledge of coding rules.
Preferred Education, Experience & Cert/Lic
Preferred Education: Master’s degree in Administration or Business.
Preferred Experience: Supervisory experience; experience with Medical Billing and Reimbursement. Pediatric experience or experience in a healthcare setting in a customer facing environment
Preferred Licenses/certificates/registrations: HBI Certifications
Additional Technical Requirements
- Requires in depth understanding of pricing and contracting terms, including managed care business processes, enrollment, and benefit design.
- Demonstrates excellence in utilization of CHOP EHR.