Revenue Cycle Specialist – Pre-Encounter Financial Clearance

Position Summary:

The Revenue Cycle Specialist – Pre-Encounter Financial Clearance is responsible for completing all financial clearance activities prior to patient encounters and scheduled procedures. This role ensures accurate insurance eligibility and benefit determination, verifies coverage alignment with planned services, secures referrals and prior authorizations, and prepares compliant Good Faith Estimates (GFEs).

This position supports both physician professional services and ambulatory surgery centers (ASCs) within a multistate eye care platform and requires effective collaboration within a team-based environment, including coordination with Global Partner labor resources.

Essential Duties and Responsibilities:

Insurance Eligibility and Benefit Determination

• Verify patient insurance eligibility and benefits prior to scheduled visits and procedures
• Analyze benefit design, including deductibles, copayments, coinsurance, out-of-pocket maximums, exclusions, and limitations
• Determine whether planned services and procedures align with the patient’s benefit design
• Identify covered and non-covered services and escalate issues as appropriate

Pre-Encounter Financial Clearance

• Complete all required financial clearance activities within established timelines
• Identify potential financial risk and communicate findings to appropriate internal teams
• Prepare accurate and compliant Good Faith Estimates (GFEs) for services and supplies in accordance with federal and state regulations

Referrals and Prior Authorizations

• Obtain referrals and prior authorizations from external physician practices and insurance companies
• Validate authorization details including CPT/HCPCS codes, ICD-10 diagnosis codes, dates of service, number of units, and site of care
• Track authorization status and resolve discrepancies prior to date of service whenever possible

Coding and Payer Policy Interpretation

• Apply a working knowledge of CPT, HCPCS, and ICD-10 coding to support benefit determinations and authorization requirements
• Research and interpret payer-specific policies, coverage determinations, and medical necessity guidelines
• Utilize payer portals, policy manuals, and other resources to validate coverage requirements

Insurance Rules and Regulatory Knowledge

• Apply insurance regulations and industry rules, including but not limited to:
  • Coordination of Benefits (COB)
  • Medicare Secondary Payer (MSP)
  • Birthday rule for dependent children
  • Determination of primary vs. secondary insurance coverage
• Maintain awareness of payer and regulatory variations across multiple states

Team Collaboration and Global Partner Coordination

• Work effectively within a team-based environment to support shared goals, coverage needs, and performance expectations
• Collaborate with internal revenue cycle teams, scheduling staff, clinical teams, and ambulatory surgery center leadership
• Partner with Global Partner labor resources to ensure consistent execution of financial clearance workflows
• Provide clear documentation, guidance, and feedback to support quality, accuracy, and process standardization across teams

Documentation and Process Improvement

• Accurately document eligibility, benefit analysis, authorizations, and financial clearance activities in practice management and augmented financial systems
• Adhere to established workflows, quality standards, production expectations and escalation protocols
• Support continuous process improvement initiatives related to pre-encounter financial clearance

Minimum Qualifications:

• High School diploma
• 2–4 years of revenue cycle management or medical financial clearance experience
• Working knowledge of CPT, HCPCS, and ICD-10
• Experience with commercial, Medicare, and Medicaid payers and authorization processes
• Demonstrated ability to research and apply payer policies
• Experience supporting physician professional or ambulatory surgical services

• Experience in ophthalmology, eye care or surgical specialties
• Experience with Ambulatory Surgery Centers
• Experience with pharmaceutical benefits and billing
• Experience working within a multistate healthcare organization
• Familiarity with No Surprises Act requirements and GFE workflows
• Experience with practice management systems, EHRs, and payer portals