Payor Clearance Associate

Children's National Hospital • Pittsburgh, PA

9d • $43,326 - $72,197 • Onsite

About The Position

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 patient 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 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)
• 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.
• Successful completion of all Patient Access training assessments required.

Nice To Haves

• Previous experience with EMRs or other related software programs preferred.
• Bilingual abilities preferred.

Responsibilities

• 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.
• 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).
• 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.
• 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.

Benefits

• Comprehensive health coverage, including medical, prescription, infertility, and transgender health services.
• Generous paid time off, including vacation accrual from day one, sick leave, holidays, and a personal day.
• Financial wellness support, including a 401(k) plan and healthcare and dependent care spending accounts.
• Employer-paid life, AD&D, and long-term disability coverage, with optional supplemental plans.
• Additional perks, including tuition assistance, fitness resources, employee assistance, commuter benefits, and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED