Patient Financial Services Rep I - (Hospital Billing)

Category:

Admin Support

City:

Jackson

State:

Tennessee

Shift:

8 - Day (United States of America)

Job Description Summary:

This position is responsible for supporting management in the billing and collection of accounts receivable for inpatient and outpatient accounts, cash application and reconciliation and/or resolving customer service issues. This position requires basic understanding of the Revenue Cycle and the importance of evaluating and securing all appropriate financial resources for patients to maximize reimbursement to the health system. The Patient Financial Services (PFS) Representative, Level 1 must also have basic knowledge of accounting, healthcare, and general office procedures, and be capable of communicating clearly and concisely, both verbally and in writing, with peers, supervisors, payers, physicians, patients, other departments, etc. The PFS Representative, Level 1 is responsible for account resolution, managing correspondence with payers, patients, and departments, and working continuously to improve aging of receivables while minimizing controllable losses. This position assumes responsibility for collecting and documenting information on behalf of the patient.
Additional responsibilities include notifying patient and/or guarantor of liabilities, verifying insurance benefits, and assisting customers regarding billing questions. The PFS Representative, Level 1 works directly with customers, physicians, and payer representatives to provide information and resolve issues. Focus on customer service and process improvements are critical to this position, as are communication and conflict resolution skills. The PFS Representative, Level 1 must complete all initial and annual training relevant to the role and comply with all relevant laws, regulations, and policies.

ESSENTIAL JOB FUNCTIONS:

• Reviews institutional and professional claims for appropriate use of procedure, modifiers and diagnostic codes to ensure maximum reimbursement using electronic billing systems and in-house computer systems to edit, modify, or change information on the UB04 and CMS-1500 claim forms for Medicare, Medicare Advantage, Medicaid/TennCare, BCBS, Commercial, and/or other third-party payers.  Resolves system edits and claim errors in a timely manner.  Governmental regulatory mandates are monitored for each claim to meet medical necessity guidelines.  Adjusts all pre-bill denials before submitting a claim according to defined procedures. Retains and applies instructions per CMS and other billing guidelines to ensure the timely submission of clean claims.
• Reviews work queues daily in order to maintain, monitor, and perform follow-up on patient accounts until benefits have been paid or resolved whereby the account can transferred to the appropriate payer work group or until the account is deemed to be self-pay and referred to the self-pay collectors.  Identify problem accounts and work towards timely resolution.  Assists in continuously improving the aging of receivables while minimizing controllable loss categories (i.e. timely filing).  Ensures hospital, federal, and payer compliance guidelines are met.
• Identifies and performs follow-up necessary to bill primary claims to appropriate insurance companies.  Update Medicare Common Working File if necessary. Identifies denied or rejected claims and makes appropriate corrections by using claims status or claims management modules, or sending hardcopy based on payer guidelines.  Works with clinical and other support departments to get corrections made to charges and claims to receive prompt and maximum payment.
• Edits, modifies, and completes UB-04 and CMS-1500 forms for secondary/tertiary payer claims following specific individual payer requirements and contracts for both hospital and physician claims.  Screens claims on-line or on paper for accuracy and obtain additional information for processing claims manually or via computerized system (EDI).
• Performs post review of all payments applied to assigned accounts to ensure payments and discounts are in compliance with regulations, guidelines, and/or policy. Adjusts denial amounts, contractual adjustment amounts, or transfer patient/guarantor responsible amounts in accordance to defined procedures.  Determines if any non-paid amounts are denied or incorrectly processed and follows approved procedures to appeal or otherwise address incorrectly denied amounts on patient accounts to include filing official appeals, reconsideration requests, or redetermination requests.  Updates any remaining balances after third-party adjudication to the correct workgroup as necessary according to defined procedures.  Responsible for the analysis and processing of correspondence including rejections, requests for medical records, itemized bills, clarification of detail on bill, etc. Analyze paid claims for accuracy of p