Payor Clearance Specialist

Join to apply for the Payor Clearance Specialist role at Children's National Hospital

Base pay range: $48,588.80/yr - $80,974.40/yr

Payor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. They work directly with referring physician offices, payers, and patients to ensure full payor clearance prior to the provision of care, serving as subject matter experts on payor requirements, authorizations, appeals, and patient navigation. Specialists use quality auditing and reporting tools to identify denial issues and trends to improve service line outcomes.

• High School Diploma or GED (required)
• 3 years of healthcare experience with payor navigation, claims and billing, medical registration, insurance referral and authorization processes, insurance authorizations, and appeals (required)
• 2 years of experience related to CPT and ICD coding assignment (required)
• Proficiency in communicating with physicians’ offices, patients, and insurance carriers in a professional manner.
• 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.
• 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 government and non‑government carriers.
• Experience with Cerner, Passport, or other related software programs and EMRs preferred.
• Successful completion of all Patient Access training assessments and minimum typing requirements.
• Bilingual abilities preferred.

• Navigate and address any payer COB issue prior to service to ensure proper claims payments.
• Obtain and ensure all authorizations are on file prior to services.
• Pre‑register patients, verify insurance eligibility and benefits, obtain pre‑certification or referral status, and collect patient responsibility amounts.
• Provide supporting clinical information to insurance payors to reduce peer‑to‑peer reviews.
• Collaborate with Payor Nurse Navigators to minimize delays in patient access.
• Establish contact with patients via inbound and outbound calls and access department work queues.
• Verify insurance eligibility and benefits using real‑time tools, payer websites, and telephone calls.

• Interpret insurance verification information to estimate patient financial responsibility amounts for scheduled services and inpatient stays.
• Act as a liaison to resolve custodial issues prior to patient arrival.
• Serve as a patient advocate to remove barriers before service.
• Review and determine insurance plan benefit information and scheduled services, including co‑insurance and deductibles.
• Communicate patient financial responsibility amounts and initiate the point‑of‑service collections process.
• Identify patients requiring payment assistance and facilitate communication with the CNMC Financial Information Center.

• Review clinical documentation for encounter support and reduce peer‑to‑peer denials.
• Measure decrease in rescheduled events due to lack of documentation.

• Educate providers on payor requirements and clinical documentation.
• Review claim denials for authorizations to identify trends, root causes, and appeal options; provide monthly reports.
• Obtain authorizations for add‑on cases and procedures; follow up and update authorizations as needed.
• Write appeal letters to payers to obtain payment; collaborate with departments to reduce first‑pass denials.

• Partner in the mission and uphold the core principles of the organization.
• Committed to diversity and recognize cultural and ethnic differences.
• Demonstrate personal and professional integrity.
• Maintain confidentiality at all times.

Primary location:
Maryland – Silver Spring
Work locations:
Dorchester
Job type:
Non‑clinical professional
Position status:
Regular (R)

Shift: Day

Work schedule:

9:00 AM – 5:30 PM

Employment type:

Full‑time