Payor Clearance Associate

Payor Clearance Associate

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. 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.

Qualifications

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.

Organizational Accountabilities

Organizational Accountabilities (Staff): Anticipate and responds to customer needs; follows up until needs are met Teamwork/Communication: Demonstrate collaborative and respectful behavior Partner with all team members to achieve goals Receptive to others' ideas and opinions Performance Improvement/Problem-solving: Contribute to a positive work environment Demonstrate flexibility and willingness to change Identify opportunities to improve clinical and administrative processes Make appropriate decisions, using sound judgment Cost Management/Financial Responsibility: Use resources efficiently Search for less costly ways of doing things Safety: Speak up when team members appear to exhibit unsafe behavior or performance Continuously validate and verify information needed for decision making or documentation Stop in the face of uncertainty and takes time to resolve the situation Demonstrate accurate, clear and timely verbal and written communication Actively promote safety for patients, families, visitors and co-workers Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

Children's National Medical Center