Payor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. Facilitate increasing our patient's access into the care continuum. Decrease payor related barriers and increase financial outcomes for scheduled patient services for the inpatient, ambulatory , and physician practice settings. Payor Clearance Specialists work directly with referring physician offices, payers, and patients to ensure full payor clearance prior to the provision of care. Including, serving e as subject matter experts as it relates to payor requirements, authorizations, appeals and patient navigation. Works as a Payor Clearance Specialists use quality auditing and reporting tools to identify denial issues and trends to improve service line outcomes.
High School Diploma or GED (Required)
Associate or Bachelor Degree in a health related or business related field. (Preferred)
Minimum Work Experience
3 years – Healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes insurance authorizations, and appeals. (Required)
2 years – Experience related to CPT and ICD coding assignment. (Required)
Comprehensive medical and insurance terminology as well as working knowledge of medical insurance plans, and managed care plans. (Required)
Ability to communicate with physicians' offices, patients and insurance carriers in a professional and courteous manner.
Superior customer service skills and professional etiquette.
Strong verbal, interpersonal, and telephone skills.
Experience in healthcare setting and computer knowledge necessary.
Attention to detail and ability to multi-task in complex situations.
Demonstrated ability to solve problems independently or as part of a team.
Knowledge of and compliance with confidentiality guidelines and CNMC policies and procedures.
Knowledge of insurance requirements and guidelines for Governmental and non-Governmental carriers.
Previous experience with Cerner, Passport, or other related software programs and EMRs preferred.
Bilingual abilities preferred.
Successful completion all Patient Access training assessments required and meets minimum typing requirements.
Pre-Service Payor Clearance
1. Navigate and address any payor COB issue prior to service being rendered to ensure proper claims payments; obtain and ensure all authorizations are on file prior to services being rendered; work collaboratively with all departments/services of the Children's National Medical Center to ensure all scheduled patients have undergone payor clearance prior to service; pre-register patients, verify insurance eligibility and benefits, obtain pre-certification or referral status, and collect patient responsibility amounts for services provided throughout the health system meeting departmental standards for productivity and quality .
2. Provide supporting clinical information to insurance payors, outcomes must decrease the need to peer-to-peer review.
3. Work with the Payor Nurse Navigators to decrease delays in patients access to care.
4. Follow established department policies to completely and accurately
5. Establish contact with patients via inbound and outbound calls and access department work queues to pre-register patients for future dates of service.
6. Verify insurance eligibility and benefits by utilizing integrated real-time eligibility tool, payer websites, and telephone calls to payers; document payer verification responses in designated fields within the registration pathway; validate insurance referral status, if applicable, and communicate with PCP office to obtain referrals.
Patient Navigation and Notification
1. Interpret insurance verification information to estimate patient financial responsibility amounts for scheduled services and inpatient stays.
2. Act as a liaison to ensure all of the appropriate custodial issues are resolved prior to the patients arrival.
3. Work as a patient advocate along with legal and other entities to remove any barriers prior to service.
4. Review and determine insurance plan benefit information and scheduled services and inpatient stays, include co-insurance and
5. deductibles. Compare and communicate in and out of network benefits accordingly.
6. Communicate patient financial responsibility amounts and initiate the point of service (POS) collections process; determine patient liability based on services level and make necessary recommendations.
7. Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center (FIC).
Revenue Cycle Outcomes
1. Review clinical documentation to ensure clinicals provided supports desired outcomes prior to submitting to payor; must document proven outcomes of decrease peer-to-peer trends.
2. Measure decrease in rescheduled events due to lack of supporting clinical documentation.
3. Provide education to providers regarding payor requirements and clinical documentation.
4. Based on cases worked and outcomes, review claim denials for authorizations to identify trends, root causes, corrective actions and appeal options, provide monthly reports to support outcomes.
5. Obtain authorizations for add-on cases and procedures to ensure proper and timely claims payment; follow-up on all cases to ensure procedures authorized were performed, update authorizations as needed.
6. Become subject matter experts on payor requirements; write appeal letters to payers to obtain payment for services; Collaborate with individual departments – Compliance Department, Patient Financial Services, Case Management, and Centers of Excellence to reduce first pass denials.
1. Partner in the mission and upholds the core principles of the organization
2. Committed to diversity and recognizes value of cultural ethnic differences
3. Demonstrate personal and professional integrity
4. Maintain confidentiality at all times
1. Anticipate and responds to customer needs; follows up until needs are met
1. Demonstrate collaborative and respectful behavior
2. Partner with all team members to achieve goals
3. Receptive to others' ideas and opinions
1. Contribute to a positive work environment
2. Demonstrate flexibility and willingness to change
3. Identify opportunities to improve clinical and administrative processes
4. Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility
1. Use resources efficiently
2. Search for less costly ways of doing things
1. Speak up when team members appear to exhibit unsafe behavior or performance
2. Continuously validate and verify information needed for decision making or documentation
3. Stop in the face of uncertainty and takes time to resolve the situation
4. Demonstrate accurate, clear and timely verbal and written communication
5. Actively promote safety for patients, families, visitors and co-workers
6. Attend carefully to important details – practicing Stop, Think, Act and Review in order to self-check behavior and performance
Children's National Health System is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law.