Payor Clearance Specialist

Job Description - Payor Clearance Specialist (250002WZ)Payor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. They facilitate increasing patient access into the care continuum, decreasing payor related barriers and increasing financial outcomes for scheduled patient services in inpatient, ambulatory, and physician practice settings. They work directly with referring physician offices, payers, and patients to ensure full payor clearance prior to the provision of care, serving as subject matter experts on payor requirements, authorizations, appeals, and patient navigation. They use quality auditing and reporting tools to identify denial issues and trends to improve service line outcomes.QualificationsMinimum EducationHigh School Diploma or GED (Required)Minimum Work Experience3 years healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral, and authorization processes and appeals (Required)2 years experience related to CPT and ICD coding assignment (Required)Required Skills/KnowledgeAbility to communicate with physicians' offices, patients, and insurance carriers professionally and courteously.Superior customer service skills and professional etiquette.Strong verbal, interpersonal, and telephone skills.Experience in a healthcare setting and required computer knowledge.Attention to detail and ability to multi‑task in complex situations.Demonstrated problem‑solving ability independently or as part of a team.Knowledge of confidentiality guidelines and CNMC policies and procedures.Knowledge of insurance requirements and guidelines for governmental and non‑governmental carriers.Experience with Cerner, Passport, or other related software programs and EMRs (preferred).Bilingual abilities (preferred).Successful completion of all Patient Access training assessments and minimum typing requirements.ResponsibilitiesPre‑Service Payor ClearanceNavigate and address payor COB issues prior to service, obtain and ensure all authorizations are on file, and collaborate with all departments to ensure all scheduled patients have undergone payor clearance before service.Provide supporting clinical information to insurance payors to decrease peer‑to‑peer review needs.Work with the Payor Nurse Navigators to decrease delays in patient access.Follow established department policies for accurate completion.Establish contact with patients via inbound/outbound calls and access department work queues to pre‑register patients for future service dates.Verify insurance eligibility and benefits using integrated real‑time eligibility tools, payer websites, and telephone calls; document payer verification responses; validate insurance referral status; communicate with PCP office to obtain referrals.Patient Navigation and NotificationInterpret insurance verification information to estimate patient financial responsibility amounts for scheduled services and inpatient stays.Act as liaison to ensure all custodial issues are resolved before patient arrival.Advocate with legal and other entities to remove barriers before service.Review insurance plan benefit information and scheduled services, including co‑insurance and deductibles; compare and communicate in‑/out‑of‑network benefits accordingly.Communicate patient financial responsibility amounts and initiate point‑of‑service collection process; determine patient liability based on service level and make recommendations.Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center.Revenue Cycle OutcomesReview clinical documentation to ensure support for desired outcomes before submitting to payor; document proven outcomes of decreased peer‑to‑peer trends.Measure decrease in rescheduled events due to lack of supporting clinical documentation.Provide education to providers regarding payor requirements and clinical documentation.Review claim denials for authorizations, identify trends, root causes, corrective actions and appeal options; provide monthly reports to support outcomes.Obtain authorizations for add‑on cases and procedures; follow‑up to ensure procedures authorized were performed and update authorizations as needed.Act as subject matter expert on payor requirements; write appeal letters to payers to obtain payment; collaborate with Compliance Department, Patient Financial Services, Case Management, and Centers of Excellence to reduce first‑pass denials.Organizational AccountabilitiesOrganizational Commitment/IdentificationPartner in the mission and uphold the core principles of the organization.Committed to diversity and recognizes value of cultural/ethnic differences.Demonstrate personal and professional integrity.Maintain confidentiality at all times.Customer ServiceAnticipate and respond to customer needs; follow up until needs are met.Teamwork/CommunicationDemonstrate collaborative and respectful behavior.Partner with all team members to achieve goals.Receptive to others' ideas and opinions.Performance Improvement/Problem‑solvingContribute to a positive work environment.Demonstrate flexibility and willingness to change.Identify opportunities to improve clinical and administrative processes.Make appropriate decisions using sound judgment.Cost Management/Financial ResponsibilityUse resources efficiently.Search for less costly ways of doing things.SafetySpeak up when team members exhibit unsafe behavior or performance.Continuously validate and verify required information for decision making or documentation.Stop in the face of uncertainty and take time to resolve the situation.Demonstrate accurate, clear and timely verbal and written communication.Actively promote safety for patients, families, visitors, and co‑workers.Attend carefully to important details through Stop, Think, Act and Review to self‑check behavior and performance.Primary LocationMaryland - Silver SpringWork LocationsDorchester 12200 Plum Orchard Dr Silver Spring 20904JobNon‑Clinical ProfessionalOrganizationFinancePosition StatusR (Regular) - FT - Full‑TimeShiftDayWork Schedule8:30am - 5:00pmFull‑Time Salary Range48,588.8 - 80,974.4Job PostingChildren's National Hospital 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. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your Rights Pay Transparency Nondiscrimination Poster.Please note that it is the policy of Children's National Hospital to ensure a “drug‑free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances by all staff (management, employees, and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug‑free workplace, including prohibiting recreational or prescribed marijuana.#J-18808-Ljbffr

Job Description - Payor Clearance Specialist (250002WZ)Payor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. They facilitate increasing patient access into the care continuum, decreasing payor related barriers and increasing financial outcomes for scheduled patient services in inpatient, ambulatory, and physician practice settings. They work directly with referring physician offices, payers, and patients to ensure full payor clearance prior to the provision of care, serving as subject matter experts on payor requirements, authorizations, appeals, and patient navigation. They use quality auditing and reporting tools to identify denial issues and trends to improve service line outcomes.QualificationsMinimum EducationHigh School Diploma or GED (Required)Minimum Work Experience3 years healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral, and authorization processes and appeals (Required)2 years experience related to CPT and ICD coding assignment (Required)Required Skills/KnowledgeAbility to communicate with physicians' offices, patients, and insurance carriers professionally and courteously.Superior customer service skills and professional etiquette.Strong verbal, interpersonal, and telephone skills.Experience in a healthcare setting and required computer knowledge.Attention to detail and ability to multi‑task in complex situations.Demonstrated problem‑solving ability independently or as part of a team.Knowledge of confidentiality guidelines and CNMC policies and procedures.Knowledge of insurance requirements and guidelines for governmental and non‑governmental carriers.Experience with Cerner, Passport, or other related software programs and EMRs (preferred).Bilingual abilities (preferred).Successful completion of all Patient Access training assessments and minimum typing requirements.ResponsibilitiesPre‑Service Payor ClearanceNavigate and address payor COB issues prior to service, obtain and ensure all authorizations are on file, and collaborate with all departments to ensure all scheduled patients have undergone payor clearance before service.Provide supporting clinical information to insurance payors to decrease peer‑to‑peer review needs.Work with the Payor Nurse Navigators to decrease delays in patient access.Follow established department policies for accurate completion.Establish contact with patients via inbound/outbound calls and access department work queues to pre‑register patients for future service dates.Verify insurance eligibility and benefits using integrated real‑time eligibility tools, payer websites, and telephone calls; document payer verification responses; validate insurance referral status; communicate with PCP office to obtain referrals.Patient Navigation and NotificationInterpret insurance verification information to estimate patient financial responsibility amounts for scheduled services and inpatient stays.Act as liaison to ensure all custodial issues are resolved before patient arrival.Advocate with legal and other entities to remove barriers before service.Review insurance plan benefit information and scheduled services, including co‑insurance and deductibles; compare and communicate in‑/out‑of‑network benefits accordingly.Communicate patient financial responsibility amounts and initiate point‑of‑service collection process; determine patient liability based on service level and make recommendations.Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center.Revenue Cycle OutcomesReview clinical documentation to ensure support for desired outcomes before submitting to payor; document proven outcomes of decreased peer‑to‑peer trends.Measure decrease in rescheduled events due to lack of supporting clinical documentation.Provide education to providers regarding payor requirements and clinical documentation.Review claim denials for authorizations, identify trends, root causes, corrective actions and appeal options; provide monthly reports to support outcomes.Obtain authorizations for add‑on cases and procedures; follow‑up to ensure procedures authorized were performed and update authorizations as needed.Act as subject matter expert on payor requirements; write appeal letters to payers to obtain payment; collaborate with Compliance Department, Patient Financial Services, Case Management, and Centers of Excellence to reduce first‑pass denials.Organizational AccountabilitiesOrganizational Commitment/IdentificationPartner in the mission and uphold the core principles of the organization.Committed to diversity and recognizes value of cultural/ethnic differences.Demonstrate personal and professional integrity.Maintain confidentiality at all times.Customer ServiceAnticipate and respond to customer needs; follow up until needs are met.Teamwork/CommunicationDemonstrate collaborative and respectful behavior.Partner with all team members to achieve goals.Receptive to others' ideas and opinions.Performance Improvement/Problem‑solvingContribute to a positive work environment.Demonstrate flexibility and willingness to change.Identify opportunities to improve clinical and administrative processes.Make appropriate decisions using sound judgment.Cost Management/Financial ResponsibilityUse resources efficiently.Search for less costly ways of doing things.SafetySpeak up when team members exhibit unsafe behavior or performance.Continuously validate and verify required information for decision making or documentation.Stop in the face of uncertainty and take time to resolve the situation.Demonstrate accurate, clear and timely verbal and written communication.Actively promote safety for patients, families, visitors, and co‑workers.Attend carefully to important details through Stop, Think, Act and Review to self‑check behavior and performance.Primary LocationMaryland - Silver SpringWork LocationsDorchester 12200 Plum Orchard Dr Silver Spring 20904JobNon‑Clinical ProfessionalOrganizationFinancePosition StatusR (Regular) - FT - Full‑TimeShiftDayWork Schedule8:30am - 5:00pmFull‑Time Salary Range48,588.8 - 80,974.4Job PostingChildren's National Hospital 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. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your Rights Pay Transparency Nondiscrimination Poster.Please note that it is the policy of Children's National Hospital to ensure a “drug‑free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances by all staff (management, employees, and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug‑free workplace, including prohibiting recreational or prescribed marijuana.#J-18808-Ljbffr

• 

• Government Careers