Job Description:
Ensures PFS departmental quality and productivity standards are met.
Collects and provides patient and payor information to facilitate account resolution.
Maintains an active working knowledge of all Government Mandated Regulations as it pertains to claims submission. Responsible to perform the necessary research in order to determine proper governmental requirements prior to claims submission.
Responds to all types of account inquires through written, verbal, or electronic correspondence.
Maintains payor-specific knowledge of insurance and self-pay billing and follow-up guidelines and regulations for third-party payers. Maintains working knowledge of all functions within the Revenue Cycle.
Responsible for professional and effective written and verbal communication with both internal and external customers in order to resolve outstanding questions for account resolution.
Meets or exceeds customer expectations and requirements, and gains customer trust and respect.
Compliant with all client's, payer, and government regulations.
Exhibits a strong working knowledge of CPT, HCPCS, and ICD-10 coding regulations and guidelines.
Appropriately documents patient accounting host system or other systems utilized by PFS in accordance with policy and procedures.
Provide continuous updates and information to the PFS Leadership Team regarding errors, issues, and trends related to activities affecting productivity, reimbursement, payment delays, and/or patient experience.
Professional and effective written and verbal communication required.
Review and work on claim edits.
Works payor rejected claims for resubmission.
Works reports and billing requests.
Demonstrates strong knowledge of standard bill forms and filing requirements.
Exhibits and understanding of electronic claims editing and submission capabilities.
Correct claims in RTP status in the designated claim system per Medicare guidelines.
Maintains an active knowledge of all governmental agency requirements and updates.
Collect balances due from payors ensuring proper reimbursement for all services.
Identifies and forwards proper account denial information to the designated departmental liaison. Dedicated efforts to ensure a proper denial resolution and timely turnaround.
Maintain an active knowledge of all governmental agency requirements and updates.
Works collector queue daily utilizing appropriate collection system and reports.
Demonstrates knowledge of standard bill forms and filing requirements.
Identify and resolve underpayments with the appropriate follow-up activities within payor timely guidelines.
Identify and resolve credit balances with the appropriate follow-up activities within payor timely guidelines.
Identify and communicate trends impacting account resolution.
Corrects claims in RTP status in the designated claim system per Medicare guidelines.
Initiates Medicare Redetermination, Reopening and/or Reconsideration as needed.
Working knowledge of the CMS 838 credit balance report.
Acts as liaison between external vendors and Revenue Cycle departments to monitor external vendor activities and ensures accounts placed for collection are received timely and acknowledged as received by the vendor.
Coordinates with Revenue Cycle Managers (Collections, Billing, Cash Applications, etc.) to review of selected accounts prior to transfer and placement with an external third party.
Ensures accounts deemed as closed or uncollectible by the vendors are properly reflected in applicable AR systems.
Maintains department reports measuring agency performance, which includes account placements, collections, returns, and performance metrics.
Recalls accounts incorrectly placed and/or as requested by Revenue Cycle Managers with the external vendor and returns accounts to open receivables as appropriate.
Requirements:
HS Diploma or equivalent years of experience required.
1-3 years of experience preferred.
Experience working within a multi-facility hospital business office environment preferred.
College education, previous Insurance Company claims experience, and/or health care billing trade school education may be considered in lieu of formal hospital experience.
Experience working with inpatient and outpatient billing requirements of UB-04 and HCFA 1500 billing forms preferred.
Experience with Medicare & Medicaid billing processes and regulations preferred.
Understanding of Medicare language.
Knowledge in locating and referencing CMS and/or Medicare Regulations preferred.