Children's National Medical Center
Payor Clearance Specialist
Children's National Medical Center, Silver Spring, Maryland, United States, 20900
Job Description - Payor Clearance Specialist (24000125)Job DescriptionPayor Clearance Specialist
-
(
24000125
)DescriptionDescription
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.
QualificationsQualifications
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. (Required)2 years Experience related to CPT and ICD coding assignment. (Required)
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.Bilingual abilities preferred.Successful completion all Patient Access training assessments required and meets minimum typing requirements.
Functional AccountabilitiesPre-Service Payor ClearanceNavigate 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 accuratelyEstablish 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 NotificationInterpret 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 anddeductibles. 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 payment assistance options and facilitate communication between patients and CNMC Financial Information Center (FIC).Revenue Cycle OutcomesReview 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 clinical documentation.Provide education to providers regarding payor requirements and clinical documentation.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 outcomes.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 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.
Organizational AccountabilitiesOrganizational Commitment/IdentificationPartner in the mission and upholds the core principles of the organizationCommitted to diversity and recognizes value of cultural ethnic differencesDemonstrate personal and professional integrityMaintain confidentiality at all timesCustomer ServiceAnticipate and responds to customer needs; follows up until needs are metTeamwork/CommunicationDemonstrate collaborative and respectful behaviorPartner with all team members to achieve goalsReceptive to others’ ideas and opinionsPerformance Improvement/Problem-solvingContribute to a positive work environmentDemonstrate flexibility and willingness to changeIdentify opportunities to improve clinical and administrative processesMake appropriate decisions, using sound judgmentCost Management/Financial ResponsibilityUse resources efficientlySearch for less costly ways of doing thingsSafetySpeak up when team members appear to exhibit unsafe behavior or performanceContinuously validate and verify information needed for decision making or documentationStop in the face of uncertainty and takes time to resolve the situationDemonstrate accurate, clear and timely verbal and written communicationActively promote safety for patients, families, visitors and co-workersAttend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
Primary Location
Primary Location
:
Maryland-Silver SpringWork Locations
Work Locations
:
Dorchester
12200 Plum Orchard Dr
Silver Spring
20904Job
Job
:
Non-Clinical ProfessionalOrganization
Organization
:
FinancePosition Status
:
R (Regular)
-
FT - Full-TimeShift
:
DayWork Schedule
:
Times may VaryJob Posting
Job Posting
:
Apr 24, 2024, 2:41:06 PMChildrens 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 Rights Pay 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.
#J-18808-Ljbffr
-
(
24000125
)DescriptionDescription
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.
QualificationsQualifications
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. (Required)2 years Experience related to CPT and ICD coding assignment. (Required)
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.Bilingual abilities preferred.Successful completion all Patient Access training assessments required and meets minimum typing requirements.
Functional AccountabilitiesPre-Service Payor ClearanceNavigate 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 accuratelyEstablish 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 NotificationInterpret 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 anddeductibles. 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 payment assistance options and facilitate communication between patients and CNMC Financial Information Center (FIC).Revenue Cycle OutcomesReview 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 clinical documentation.Provide education to providers regarding payor requirements and clinical documentation.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 outcomes.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 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.
Organizational AccountabilitiesOrganizational Commitment/IdentificationPartner in the mission and upholds the core principles of the organizationCommitted to diversity and recognizes value of cultural ethnic differencesDemonstrate personal and professional integrityMaintain confidentiality at all timesCustomer ServiceAnticipate and responds to customer needs; follows up until needs are metTeamwork/CommunicationDemonstrate collaborative and respectful behaviorPartner with all team members to achieve goalsReceptive to others’ ideas and opinionsPerformance Improvement/Problem-solvingContribute to a positive work environmentDemonstrate flexibility and willingness to changeIdentify opportunities to improve clinical and administrative processesMake appropriate decisions, using sound judgmentCost Management/Financial ResponsibilityUse resources efficientlySearch for less costly ways of doing thingsSafetySpeak up when team members appear to exhibit unsafe behavior or performanceContinuously validate and verify information needed for decision making or documentationStop in the face of uncertainty and takes time to resolve the situationDemonstrate accurate, clear and timely verbal and written communicationActively promote safety for patients, families, visitors and co-workersAttend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
Primary Location
Primary Location
:
Maryland-Silver SpringWork Locations
Work Locations
:
Dorchester
12200 Plum Orchard Dr
Silver Spring
20904Job
Job
:
Non-Clinical ProfessionalOrganization
Organization
:
FinancePosition Status
:
R (Regular)
-
FT - Full-TimeShift
:
DayWork Schedule
:
Times may VaryJob Posting
Job Posting
:
Apr 24, 2024, 2:41:06 PMChildrens 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 Rights Pay 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.
#J-18808-Ljbffr