Payor Clearance Associate-1

12211 Plum Orchard Drive, Silver Spring, MD 20904

Department: Eligibility and Financial Clearance

About the Role

Payor 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. They facilitate increasing patients' access into the care continuum, decrease payor-related barriers, and improve 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.

Requirements

• High School Diploma or GED (Required)
• 2 years of healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes, and appeals (Required)
• 2 years of experience related to CPT, ICD coding assignment, and medical terminology (Required)
• 2 years of comprehensive medical and insurance terminology as well as working knowledge of medical insurance plans and managed care plans (Required)

Skills

• 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 a healthcare setting and computer knowledge
• 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

Responsibilities

Pre-Service Payor Clearance

• Navigate and address any payor coordination of benefits (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 departments/services 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 and update authorizations as needed
• Provide supporting clinical information to insurance payors to 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 it supports desired outcomes prior to submitting to payor; 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 tools, 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 primary care physician (PCP) offices 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 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; 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 it supports desired outcomes prior to submitting to payer; document proven outcomes of decreased 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
• 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

Pay

Pay Range: $43,326.40 - $72,196.80

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 will be based on a variety of factors in alignment with the Children’s National compensation philosophy, including the individual’s combination of prior work experience, level of education, knowledge, skills, and other qualifications.