Patient Financial Services Rep I

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Job description

Overview:
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 a 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. This position assumes responsibility for collecting and documenting information on behalf of the patient.
Additional responsibilities include notifying the patient and/or guarantor of liabilities, verifying insurance benefits, and assisting customers regarding billing questions. 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.

Responsibilities:
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 claims 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 be transferred to the appropriate payer workgroup or until the account is deemed to be self-pay and referred to the self-pay collectors. Identify problem accounts and work towards a timely resolution. Assists in continuously improving the aging of receivables while minimizing controllable loss categories. 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 claim online or on paper for accuracy and obtain additional information for processing claims manually or via a computerized system.
Performs post review of all payments applied to assigned accounts to ensure payments and discounts are in compliance with regulations, guidelines, and/or policy.

Customer Service
Ensures that incoming call volumes are processed expeditiously and communicates effectively in all patient interactions.
Conducts in-person patient interviews for customer service needs.
Ensures that incoming correspondence is processed expeditiously.
Ensures that all written responses are clearly and professionally communicated.

Communication
Serves as contact for others regarding questions/account issue resolution. Mentors and trains other staff.

Other
Takes personal accountability for professional growth and development.

Qualifications:
EDUCATION:
High School Diploma required.

LICENSURE, REGISTRATION, CERTIFICATION:
N/A

EXPERIENCE:
1-2 years of healthcare or related experience preferred.
Knowledge of medical billing and collections or other financial policies and procedures and must possess the ability to perform medical billing, collection, or customer service functions as normally acquired through related work experience or the equivalent of three (3) months of on-the-job training.