Payor Clearance Associate 1

12211 Plum Orchard Drive
Silver Spring, MD 20904


Kids Are Our Everything.

Department

10119 Eligibility and Financial Clearance

Pay Range

$43,326.40 - $72,196.80Payor Clearance Associates are members of the Revenue Cycle team dedicated to completing patient access and patient financial 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)

Minimum Work Experience
2 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, ICD coding assignment, and medical terminology (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 EMRs or other related software programs preferred.
Bilingual abilities preferred.
Successful completion of all Patient Access training assessments required.

Functional Accountabilities
Pre-Service Payor Clearance

• 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.

• 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.

• Provide supporting clinical information to insurance payors; outcomes should decrease the need for peer-to-peer review.

• Work with the Payor Nurse Navigators to decrease delays in patients access to care.

• 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.

• Establish contact with patients via inbound and outbound calls, as needed, to pre-register patients for future dates of service.

• 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

• Interpret insurance verification information to estimate patient financial responsibility amounts for scheduled services and inpatient stays.

• Act as a liaison to ensure all of the appropriate custodial issues are resolved prior to the patient’s arrival.

• Work as a patient advocate along with legal and other entities to remove any barriers prior to service.

• 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.

• 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.

• Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center (FIC).

Revenue Cycle Outcomes

• Review clinical documentation to ensure clinicals provided supports desired outcomes prior to submitting to payer; must document proven outcomes of decrease peer-to-peer trends.

• Provide monthly trends for appeals, denials, and approvals demonstrating a decrease in rescheduled events due to lack of supporting clinical documentation to identify root causes and corrective actions.

• Provide education to providers regarding payer requirements and clinical documentation.

• 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.

• Become a subject matter expert on payer 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.

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. It is not typical for an individual to be hired at or near the maximum of the pay range. The exact pay rate for this position will be based on a variety of factors in alignment with the Children’s National compensation philosophy. These factors are legitimate and non-discriminatory including, but not limited to, the current market conditions; organizational needs; the individual’s combination of prior work experience, level of education, knowledge, skills, and other qualifications. Children’s National is committed to providing a fair and competitive total rewards package to each of our employees. This base salary range does not include our comprehensive benefits package or any additional compensation for which this position may be eligible.

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. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your RightsPay 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.