Children's National Medical Center
Payor Clearance Associate
Children's National Medical Center, Silver Spring, Maryland, United States, 20900
Payor Clearance Associate (250002OC)
Payor Clearance Associates are members of the Revenue Cycle team dedicated to completing patient access and 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 increase financial outcomes for scheduled services. They 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 of healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes, and appeals (Required)
2 years of experience related to CPT, ICD coding assignment, and medical terminology (Required)
2 years of 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 physician offices, patients and insurance carriers professionally and courteously
Superior customer service skills and professional etiquette
Strong verbal, interpersonal, and telephone skills
Experience in a healthcare setting and computer knowledge
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 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 payor COB issues prior to services to ensure proper claims payments; obtain and ensure all authorizations are on file prior to services.
Work collaboratively with assigned departments to ensure all scheduled patients have undergone payor clearance before service; pre‑register patients, verify insurance eligibility and benefits, obtain pre‑certification or referral status, and collect patient responsibility amounts.
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 to 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 it supports desired outcomes prior to submitting to payor; 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 using integrated real‑time tools, payer websites, and telephone calls to payers; document responses in designated fields; validate insurance referral status; 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 appropriate custodial issues are resolved prior to the patient’s arrival.
Work as a patient advocate along with legal and other entities to remove barriers prior to service.
Review and determine insurance plan benefit information for scheduled services, including co‑insurance and deductibles; compare and communicate in‑network and out‑of‑network benefits accordingly.
Communicate patient financial responsibility amounts and initiate the point‑of‑service 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 it supports desired outcomes prior to submitting to payor; document proven outcomes of decreased 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; 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 Commitment/Identification
Anticipate and respond to customer needs; follow 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 take 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 to self‑check behavior and performance.
Primary Location Maryland – Silver Spring
Work Locations Dorchester 12200 Plum Orchard Dr Silver Spring 20904
Job Non-Clinical Professional
Organization Finance
Position Status: R (Regular) – FT – Full-Time
Shift: Day
Work Schedule: 8:30 am – 5 pm
Job Posting Oct 6, 2025, 6:45:51 AM
Full-Time Salary Range 41,288 – 68,806.40
Children’s 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.
Children’s National Hospital maintains a drug‑free workplace in accordance with the Controlled Substances Act. Although recreational and medical marijuana are legal in the District of Columbia, the hospital’s policy prohibits the use, possession, or distribution of illegal substances, as well as the misuse of legal substances, by all staff.
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Qualifications Minimum Education
High School Diploma or GED (Required)
Minimum Work Experience
2 years of healthcare experience with payor navigation, claims and billing, healthcare registration, insurance referral and authorization processes, and appeals (Required)
2 years of experience related to CPT, ICD coding assignment, and medical terminology (Required)
2 years of 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 physician offices, patients and insurance carriers professionally and courteously
Superior customer service skills and professional etiquette
Strong verbal, interpersonal, and telephone skills
Experience in a healthcare setting and computer knowledge
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 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 payor COB issues prior to services to ensure proper claims payments; obtain and ensure all authorizations are on file prior to services.
Work collaboratively with assigned departments to ensure all scheduled patients have undergone payor clearance before service; pre‑register patients, verify insurance eligibility and benefits, obtain pre‑certification or referral status, and collect patient responsibility amounts.
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 to 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 it supports desired outcomes prior to submitting to payor; 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 using integrated real‑time tools, payer websites, and telephone calls to payers; document responses in designated fields; validate insurance referral status; 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 appropriate custodial issues are resolved prior to the patient’s arrival.
Work as a patient advocate along with legal and other entities to remove barriers prior to service.
Review and determine insurance plan benefit information for scheduled services, including co‑insurance and deductibles; compare and communicate in‑network and out‑of‑network benefits accordingly.
Communicate patient financial responsibility amounts and initiate the point‑of‑service 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 it supports desired outcomes prior to submitting to payor; document proven outcomes of decreased 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; 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 Commitment/Identification
Anticipate and respond to customer needs; follow 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 take 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 to self‑check behavior and performance.
Primary Location Maryland – Silver Spring
Work Locations Dorchester 12200 Plum Orchard Dr Silver Spring 20904
Job Non-Clinical Professional
Organization Finance
Position Status: R (Regular) – FT – Full-Time
Shift: Day
Work Schedule: 8:30 am – 5 pm
Job Posting Oct 6, 2025, 6:45:51 AM
Full-Time Salary Range 41,288 – 68,806.40
Children’s 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.
Children’s National Hospital maintains a drug‑free workplace in accordance with the Controlled Substances Act. Although recreational and medical marijuana are legal in the District of Columbia, the hospital’s policy prohibits the use, possession, or distribution of illegal substances, as well as the misuse of legal substances, by all staff.
#J-18808-Ljbffr