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
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.
2 years - Experience related to CPT and ICD coding assignment.
Comprehensive medical and insurance terminology as well as
working knowledge of medical insurance plans, and managed care
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
Attention to detail and ability to multi-task in complex
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
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 .
Provide supporting clinical information to insurance payors,
outcomes must decrease the need to peer-to-peer review.
Work with the Payor Nurse Navigators to decrease delays in
patients access to care.
Follow established department policies to completely and
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 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
Act as a liaison to ensure all of the appropriate custodial
issues are resolved prior to the patients 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 and
scheduled services and inpatient stays, include co-insurance
deductibles. Compare and communicate in and out of network
Communicate patient financial responsibility amounts and
initiate the point of service (POS) collections process; determine
patient liability based on services level and make necessary
- 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 payor; must
document proven outcomes of decrease peer-to-peer trends.
Measure decrease in rescheduled events due to lack of supporting
Provide education to providers regarding payor requirements and
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
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
- 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.
Partner in the mission and upholds the core principles of the
Committed to diversity and recognizes value of cultural ethnic
Demonstrate personal and professional integrity
- Maintain confidentiality at all times
- Anticipate and responds to customer needs; follows up until
needs are met
Demonstrate collaborative and respectful behavior
Partner with all team members to achieve goals
- Receptive to others' ideas and opinions
Contribute to a positive work environment
Demonstrate flexibility and willingness to change
Identify opportunities to improve clinical and administrative
- Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility
Use resources efficiently
- Search for less costly ways of doing things
Speak up when team members appear to exhibit unsafe behavior or
Continuously validate and verify information needed for decision
making or documentation
Stop in the face of uncertainty and takes time to resolve the
Demonstrate accurate, clear and timely verbal and written
Actively promote safety for patients, families, visitors and
- Attend carefully to important details - practicing Stop, Think,
Act and Review in order to self-check behavior and performance