Patient Financial Services Representative II - Days

Full time (40 hours weekly)
Monday - Friday dayshift

General Summary

Completes assigned revenue cycle tasks. Acts as SME for coworkers, assisting in the completion of Patient Financial Services tasks as needed. Performs Revenue Cycle functions including, submitting electronic and / or manual insurance claims, resolves claim edits, performs insurance account follow-up, researches claim denial for resolution and submits disputes and appeals. Represents the System in a professional manner while interacting with patients and third-party payers to achieve payment on accounts in accordance with current government and payer regulations.

Duties and Responsibilities

Essential Functions:

• Performs various functions to complete and expedite the billing process including: • Reviews and submits Hospital and/or Physician claim forms (UB04, 1500, etc) to insurance companies via electronic or manual processes and facilitates special billing for split claims, ancillary charges, interim bills, etc.• Resolves Claim edits to facilitate timely billing and reimbursement.• Performs follow-up with insurance companies to obtain claim status, payment and to resolve claim discrepancies.• Submits itemized bills, medical records, and corrected claims as needed.• Reviews remittance advice (835) to ensure proper reimbursement.• Interacts directly with department staff, Revenue Integrity, HIM and payer representatives to resolve line level denials.• Provides trend analysis to management, leadership, and insurance liaison.• Writes and submits appeals when needed to overturn claim denials.• Accesses external payer sites for payer policies, claim investigations, and claim disputes.
• Reviews accounts and coordinates with appropriate departments on accounts requiring precertification, preauthorization, referral forms, coding and other requirements related to ensuring claim payment.
• Updates financial and demographic information that may have been incorrectly entered into the billing system.
• Reviews accounts and makes written and/or verbal inquiries to third party payers to reconcile patient accounts. Follows up on accounts until outstanding insurance balance is zero.
• Reviews third party payer payments and investigates accounts not paid as expected. Takes appropriate corrective action to include follow up, rebilling, and/or adjustment of contractual allowances.
• Researches and works underpayment or overpayment as appropriate and works with Credits/Refunds or PRA team for refunds to third party payer per state / federal regulations or contract terms.
• Assists Team Lead and Supervisor with onboarding and training new staff, as requested.
• Works to resolve billing problems and/or receives insurance updates and acts as a first line of support to PFS I billing staff in resolving billing issues.
• Identifies trends, quantifies impact, and escalates as appropriate for resolution.
• Acts as a Team Lead in the absence of one.
• Assumes responsibility to lead projects as requested; may also lead process improvement initiatives for the department.

Common Expectations:

• Documents claim issues, root cause, action taken, and next steps planned in billing system.
• Maintains department records, reports, files as required.
• Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
• Participates in educational programs and in-service meetings.
• Provides outstanding service to all; fosters teamwork; embraces positive change and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• High School Diploma or GED Required

Work Experience:

• 2 years Experience in Healthcare Revenue Cycle, Patient Financial Services and/or Billing. Required

Licenses:

• Certified Revenue Cycle Professional within 1 year Required or
• Certified Revenue Cycle Representative within 1 year Required or
• Certified Revenue Cycle Specialist within 1 year Required or
• Certified Patient Accounts Manager within 1 year Required or
• Certified Coding Associate within 1 year Required or
• Certified Coding Specialist within 1 year Required or
• Certified Coding Specialist - Physician Based within 1 year Required or
• Certified Healthcare Financial Professional within 1 year Required or
• Certified Outpatient Coder within 1 year Required or
• Certified Professional Coder within 1 year Required or
• Certified Professional Coder Apprentice within 1 year Required

Knowledge, Skills, and Abili