Payor Clearance Specialist

Job Description - Payor Clearance Specialist (250002WZ)

Payor Clearance Specialists are members of the Patient Access team dedicated to completing patient access workflows related to navigating insurance payor regulations. They facilitate increasing patient access into the care continuum, decreasing payor related barriers and increasing financial outcomes for scheduled patient services in inpatient, ambulatory, and physician practice settings. 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.

They use quality auditing and reporting tools to identify denial issues and trends to improve service line outcomes.

Minimum Education
High School Diploma or GED (Required)

Minimum Work Experience
3 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 and ICD coding assignment (Required)

Required Skills/Knowledge
Ability to communicate with physicians’ 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 required computer knowledge.
Attention to detail and ability to multi‑task in complex situations.
Demonstrated problem‑solving ability 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.

Experience with Cerner, Passport, or other related software programs and EMRs (preferred).
Bilingual abilities (preferred).
Successful completion of all Patient Access training assessments and minimum typing requirements.

• Navigate and address payor COB issues prior to service, obtain and ensure all authorizations are on file, and collaborate with all departments to ensure all scheduled patients have undergone payor clearance before service.
• Provide supporting clinical information to insurance payors to decrease peer‑to‑peer review needs.
• Work with the Payor Nurse Navigators to decrease delays in patient access.
• Follow established department policies for accurate completion.
• Establish contact with patients via inbound/outbound calls and access department work queues to pre‑register patients for future service dates.
• Verify insurance eligibility and benefits using integrated real‑time eligibility tools, payer websites, and telephone calls; document payer verification responses; validate insurance referral status; 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 liaison to ensure all custodial issues are resolved before patient arrival.
• Advocate with legal and other entities to remove barriers before service.
• Review insurance plan benefit information and scheduled services, including co‑insurance and deductibles; compare and communicate in‑/out‑of‑network benefits accordingly.
• Communicate patient financial responsibility amounts and initiate point‑of‑service collection process; determine patient liability based on service level and make recommendations.
• Identify patients requiring payment assistance options and facilitate communication between patients and CNMC Financial Information Center.

• Review clinical documentation to ensure support for desired outcomes before submitting to payor; document proven outcomes of decreased peer‑to‑peer trends.
• Measure decrease in rescheduled events due to lack of supporting clinical documentation.
• Provide education to providers regarding payor requirements and clinical documentation.
• Review claim denials for authorizations, identify trends, root causes, corrective actions and appeal options; provide…