Payor Clearance Associate (PRN | As Needed)

Silver Spring, Maryland-Silver Spring
Dec 10, 2020
Jan 14, 2021
Full Time
Payor Clearance Associates are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance prior authorization processes for assigned services. Facilitate increasing our patient's access into the care continuum. Decrease payor related barriers and increase financial outcomes for scheduled services. Payor Clearance Associates work directly with referring physician offices, payers, and patients to ensure full payor clearance prior to the provision of care.


Minimum Education
High School Diploma or GED (Required)

Associate or Bachelor Degree in a health related or business related field. (Preferred)

Minimum Work Experience
2 years - Healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes. (Required)

2 years - Comprehensive medical and insurance terminology as well as working knowledge of medical insurance plans, and managed care plans. (Required)

Required Skills/Knowledge
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, Experian, or other related software programs and EMRs preferred.
Bilingual abilities preferred.
Successful completion of all Patient Access training assessments required.

Functional Accountabilities

Pre-Service Payor Clearance
1. Navigate and address any payor COB issues prior to services being rendered to ensure proper claims payments; obtain and ensure all authorizations are on file prior to services being rendered; work collaboratively with assigned department (s)/service(s) of the Children's National Hospital 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. 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.
3. Provide supporting clinical information to insurance payors; outcomes should decrease the need for peer-to-peer review.
4. Work with the Payor Nurse Navigators to decrease delays in patients access to care.
5. Review clinical documentation to ensure clinicals provided support desired outcomes prior to submitting to payor; must document proven outcomes of decreased peer-to-peer trends.
6. Establish contact with patients via inbound and outbound calls, as needed, to pre-register patients for future dates of service.
7. 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 patient's 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 for scheduled services, including co-insurance and deductibles; compare and communicate in and out of network benefits accordingly.
5. Communicate patient financial responsibility amounts and initiate the point of service (POS) collections process; determine patient liability based on service levels and make necessary recommendations.
6. Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center (FIC).

Childrens 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.

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