Kids Are Our Everything.Job OverviewPayor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. They facilitate increasing patients' access into the care continuum, decreasing payor-related barriers and improving financial outcomes in inpatient, ambulatory, and physician practice settings. Specialists work directly with referring physician offices, payers, and patients to ensure full payor clearance before care is provided and serve as subject matter experts on payor requirements, authorizations, appeals, and patient navigation.Minimum 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, insurance authorizations, and appeals.2 years experience related to CPT and ICD coding assignment.Required Skills / KnowledgeAbility 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.Successful completion of all Patient Access training assessments required and meets minimum typing requirements.Functional AccountabilitiesPre‑Service Payor ClearanceNavigate and address any payor COB issue before service to ensure proper claims payments; obtain authorizations on file prior to services.Work collaboratively with all departments to ensure all scheduled patients have undergone payor clearance before service; pre‑register patients, verify insurance eligibility and benefits, obtain pre‑certification or referral status, and collect patient responsibility amounts.Provide supporting clinical information to insurance payors to decrease the need for peer‑to‑peer review.Work with the Payor Nurse Navigators to reduce delays in patient access to care.Follow established department policies to complete tasks accurately.Establish contact with patients via inbound and outbound calls and access department work queues to pre‑register patients for future dates of service.Verify insurance eligibility and benefits using real‑time eligibility tools, payer websites, and phone calls; document responses; validate referral status and communicate with PCP office to obtain referrals.Patient Navigation and NotificationInterpret insurance verification information to estimate patient financial responsibility amounts for scheduled services.Act as a liaison to resolve custodial issues before patient arrival.Advocate as needed to remove barriers before service.Review and determine insurance plan benefit information for scheduled services and inpatient stays, including co‑insurance and deductibles, compare and communicate in‑network and out‑of‑network benefits.Communicate patient financial responsibility amounts and initiate point‑of‑service collections; determine liability based on service level and make necessary recommendations.Identify patients requiring payment assistance and facilitate communication between patients and CNMC Financial Information Center.Revenue Cycle OutcomesReview clinical documentation to ensure it supports 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 documentation.Provide education to providers regarding payor requirements and clinical documentation.Review claim denials for authorizations to identify trends, root causes, corrective actions and appeal options; provide monthly reports.Obtain authorizations for add‑on cases and procedures to ensure proper and timely claims payment; follow‑up on all cases to ensure authorized procedures were performed and update authorizations as needed.Become subject‑matter expert on payor requirements; write appeal letters to payers to obtain payment for services; collaborate with compliance, patient financial services, case management and centers of excellence to reduce first‑pass denials.BenefitsComprehensive health coverage, including medical, prescription, infertility, and transgender health services.Generous paid time off, including vacation accrual from day one, sick leave, holidays, and a personal day.Financial wellness support, including a 401(k) plan and healthcare and dependent care spending accounts.Employer‑paid life, AD&D, and long‑term disability coverage, with optional supplemental plans.Additional perks, including tuition assistance, fitness resources, employee assistance, commuter benefits, and more.The disclosed salary range includes the minimum and maximum rates within which Children's National believes an individual's base pay rate will fall for this position. The exact pay rate for this position will be based on a variety of factors in alignment with Children's National compensation philosophy.Equal Opportunity EmployerChildrens 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.Drug‑Free WorkplaceChildren's National Hospital maintains a drug‑free workplace and prohibits the illegal use, possession or distribution of controlled substances or misuse of legal substances by all staff.#J-18808-Ljbffr
Kids Are Our Everything.Job OverviewPayor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. They facilitate increasing patients' access into the care continuum, decreasing payor-related barriers and improving financial outcomes in inpatient, ambulatory, and physician practice settings. Specialists work directly with referring physician offices, payers, and patients to ensure full payor clearance before care is provided and serve as subject matter experts on payor requirements, authorizations, appeals, and patient navigation.Minimum 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, insurance authorizations, and appeals.2 years experience related to CPT and ICD coding assignment.Required Skills / KnowledgeAbility 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.Successful completion of all Patient Access training assessments required and meets minimum typing requirements.Functional AccountabilitiesPre‑Service Payor ClearanceNavigate and address any payor COB issue before service to ensure proper claims payments; obtain authorizations on file prior to services.Work collaboratively with all departments to ensure all scheduled patients have undergone payor clearance before service; pre‑register patients, verify insurance eligibility and benefits, obtain pre‑certification or referral status, and collect patient responsibility amounts.Provide supporting clinical information to insurance payors to decrease the need for peer‑to‑peer review.Work with the Payor Nurse Navigators to reduce delays in patient access to care.Follow established department policies to complete tasks accurately.Establish contact with patients via inbound and outbound calls and access department work queues to pre‑register patients for future dates of service.Verify insurance eligibility and benefits using real‑time eligibility tools, payer websites, and phone calls; document responses; validate referral status and communicate with PCP office to obtain referrals.Patient Navigation and NotificationInterpret insurance verification information to estimate patient financial responsibility amounts for scheduled services.Act as a liaison to resolve custodial issues before patient arrival.Advocate as needed to remove barriers before service.Review and determine insurance plan benefit information for scheduled services and inpatient stays, including co‑insurance and deductibles, compare and communicate in‑network and out‑of‑network benefits.Communicate patient financial responsibility amounts and initiate point‑of‑service collections; determine liability based on service level and make necessary recommendations.Identify patients requiring payment assistance and facilitate communication between patients and CNMC Financial Information Center.Revenue Cycle OutcomesReview clinical documentation to ensure it supports 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 documentation.Provide education to providers regarding payor requirements and clinical documentation.Review claim denials for authorizations to identify trends, root causes, corrective actions and appeal options; provide monthly reports.Obtain authorizations for add‑on cases and procedures to ensure proper and timely claims payment; follow‑up on all cases to ensure authorized procedures were performed and update authorizations as needed.Become subject‑matter expert on payor requirements; write appeal letters to payers to obtain payment for services; collaborate with compliance, patient financial services, case management and centers of excellence to reduce first‑pass denials.BenefitsComprehensive health coverage, including medical, prescription, infertility, and transgender health services.Generous paid time off, including vacation accrual from day one, sick leave, holidays, and a personal day.Financial wellness support, including a 401(k) plan and healthcare and dependent care spending accounts.Employer‑paid life, AD&D, and long‑term disability coverage, with optional supplemental plans.Additional perks, including tuition assistance, fitness resources, employee assistance, commuter benefits, and more.The disclosed salary range includes the minimum and maximum rates within which Children's National believes an individual's base pay rate will fall for this position. The exact pay rate for this position will be based on a variety of factors in alignment with Children's National compensation philosophy.Equal Opportunity EmployerChildrens 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.Drug‑Free WorkplaceChildren's National Hospital maintains a drug‑free workplace and prohibits the illegal use, possession or distribution of controlled substances or misuse of legal substances by all staff.#J-18808-Ljbffr
