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Employment Type:
Full time
Job Category:
Health Care Provider
Health Care & Medicine
Payor Clearance Specialist
(This job is no longer available)
Children's National Health System | Silver Spring, MD
Grad Date

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Job Description


 Minimum Education
High School Diploma or GED

Specific Requirements and Preferences
High School diploma or equivalent. Associate or Bachelor Degree in a health related or business related field preferred.

Minimum Work Experience
3 Year(s)

Specific Requirements and Preferences
At least 3 years of healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes insurance authorizations, and appeals. At least 2 years of 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 plans.

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
  1. 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.
  2. Provide supporting clinical information to insurance payors, outcomes must decrease the need to peer-to-peer review.
  3. Work with the Payor Nurse Navigators to decrease delays in patients access to care.
  4. Follow established department policies to completely and accurately
  5. Establish contact with patients via inbound and outbound calls and access department work queues to pre-register patients for future dates of service.
  6. 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
  1. Interpret insurance verification information to estimate patient financial responsibility amounts for scheduled services and inpatient stays.
  2. Act as a liaison to ensure all of the appropriate custodial issues are resolved prior to the patients arrival.
  3. Work as a patient advocate along with legal and other entities to remove any barriers prior to service.
  4. 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.
  5. 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.
  6. Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center (FIC).
Revenue Cycle Outcomes
  1. 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.
  2. Measure decrease in rescheduled events due to lack of supporting clinical documentation.
  3. Provide education to providers regarding payor requirements and clinical documentation.
  4. 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.
  5. 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.
  6. 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.

  1. Perform the duties listed above and other duties as assigned.

Organizational Accountabilities (Staff)

Organizational Commitment/Identification
  1. Partner in the mission and upholds the core principles of the organization
  2. Committed to diversity and recognizes value of cultural ethnic differences
  3. Demonstrate personal and professional integrity
  4. Maintain confidentiality at all times
Customer Service
  1. Anticipate and responds to customer needs; follows up until needs are met
  1. Demonstrate collaborative and respectful behavior
  2. Partner with all team members to achieve goals
  3. Receptive to others’ ideas and opinions
Performance Improvement/Problem-solving
  1. Contribute to a positive work environment
  2. Demonstrate flexibility and willingness to change
  3. Identify opportunities to improve clinical and administrative processes
  4. Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility
  1. Use resources efficiently
  2. Search for less costly ways of doing things
  1. Speak up when team members appear to exhibit unsafe behavior or performance
  2. Continuously validate and verify information needed for decision making or documentation
  3. Stop in the face of uncertainty and takes time to resolve the situation
  4. Demonstrate accurate, clear and timely verbal and written communication
  5. Actively promote safety for patients, families, visitors and co-workers
  6. Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

About Children's National Health System

Childrens National Medical Center is the only exclusive provider of pediatric care in the metropolitan Washington area and is the only freestanding childrens hospital between Philadelphia, Pittsburgh, Norfolk, and Atlanta. Serving the nations children for more than 130 years, Childrens National is a proven leader in the development and application of innovative new treatments for childhood illness and injury.

Childrens National is proudly ranked consistently among the best pediatric hospitals in America by US News & World Report.

Our Culture

Children's mission is to be preeminent in providing pediatric health care services that enhance the health and well-being of children regionally, nationally and internationally. Through leadership and innovation, Children's creates solutions to pediatric healthcare problems. Children's excels in Care, Advocacy, Research, and Education to meet the unique needs of children, adolescents and their families. Children's leadership realizes that our employees are the heart of our medical center and the soul of our mission. One of our greatest assets is the diversity of our workforce, which adds to the richness of our culture. Teamwork, dedication, and professionalism are essential values and characteristics that make our employees unique.

Childrens internationally recognized team of pediatric healthcare professionals care for more than 360,000 patients each year who come from throughout the region, nation and world. Our employees share a sense of pride and commitment to the patients and families we serve. We aspire to provide patients and their families with the highest quality of care and service in a family-centered environment. In essence, we are a team of "Great People Providing Great Care."

Nursing Students

As a nursing student, you might already be craving hands-on experience at a highly respected hospital. You may be thinking about where or with which population you want to work after graduation.

At Childrens, a world-class teaching hospital and internationally-recognized leader in pediatric health, we invite nursing students at all stages of learning to explore the real world of working in a hospital setting and experience first-hand the challenges and rewards of this career.

Internship Program

The internship program provides the novice nurse with the knowledge base and skill set needed to transition to competence in clinical nursing practice. While providing the needed skills to meet the organization goals and mission, the program provides nurses with the leadership skills to work collaboratively within a multidisciplinary team. The program bridges the gap between undergraduate education and real-life professional nursing practice, delivering state-of-the art pediatric care.

The program is offered to new graduate nurses from an accredited nursing program with a passion for children. All new graduates, with less than one-year acute care experience, are eligible to participate in the program after obtaining licensure.