JobsUSAPayor Clearance Specialist
Company : Children's National Hospital
Location : Silver Spring, MD, 20900
Posted Date : 15 September 2025
Job Details
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 outcomes.
Qualifications:
Minimum Education
High School Diploma or GED (Required)
Minimum Work Experience
3 years Healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes insurance authorizations, and appeals. (Required)
2 years Experience related to CPT and ICD coding assignment. (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, 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.
Functional Accountabilities
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 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 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.
- 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 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 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 services level and make necessary recommendations.
- Identify patients requiring
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