PFS Representative III - Denials Specialist

SUMMARY:

May perform the following based on job role as defined under essential functions.  Performs Medicare billing and follow up, commercial and state Medicaid appeals, preparation for state Medicaid state fair hearings. Prepares refunds for payers and patient accounts which includes a complex review and reconciliation of government and non-government payers. Resolves problematic accounts demonstrating complete understanding of payer contracts and or payer requirements to ensure timely and accurate payments or timely responses on credits, recoupments, and refund requests. May be responsible for balancing all cash receipts and daily/monthly workbook with the finance department. (job specific).  Makes independent decisions based on payer guidelines for reconciling, billing and or credit balances on accounts.

ESSENTIAL FUNCTIONS:

• Assists management in maintaining or reducing account receivable (AR) days to meet industry standards and improve organizational cash flows.
• Ensures UB04 and HCFA 1500 claims and/or self-pay patient accounts are billed in a timely, complete, and accurate manner in accordance with appropriate guidelines.
• Provides information regarding patient accounts in response to inquiries, safeguarding confidential information in verbal replies and correspondence.
• Demonstrates understanding of the entire revenue cycle. 
• Provides routine daily internal and external interface with unit/department management and staff, other service areas, information systems, physicians, physicians’ office staff, patients, software/hardware vendors, and third-party payers in order to resolve patient concerns, disputes, and billing audits in order to receive payment.
• Assists with problem solving, inquiries, and customer interaction to ensure positive results.
• Researches and analyzes any correspondence received related to assigned accounts.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 
• Analyzes patient accounts, determines non-collectable accounts, and recommends bad debt or charity write-offs when applicable; analyzes and processes contractual write offs.
• Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.
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• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Ensures patient accounts are refunded and/or billed in a timely, complete, and accurate manner in accordance with payer contracts and payer guidelines, and/or billing and follow-up guidelines (depends on review and reconciliation process).
• Prepares and enters contractual write-offs and dispute letters to Medicare or insurance carriers as required.
• Serves as information resource to patients and hospital staff regarding credit and collection policies or Medicare polices and benefits.
• Analyzes and prepares commercial/Medicaid payer claim denial reconsiderations and or formal disputes as needed on non-clinical denials based on payer guidelines.
• Follows up on all appealed claims assigned, escalating as needed based on appeal levels with the payer.
• Maintains online payer resource reference library related to payer policies utilized for follow up and or appeals.
• Reviews/analyzes payer driven denial reason codes to determine root cause of the denial. Submits recommendations to Management on any identified trends in order to assist in reducing denials.
• Trains and assists in the implementation of new software programs/systems and related technologies.
• Performs related duties as assigned.

Performs complex reviews and reconciliation of non-clinical denied commercial and Medicaid claims.  Communicates with insurance companies and issues related to claim denials. Files corrected claims or levels of appeals as appropriate. Works independently to resolve problems and demonstrates complete understanding of payer requirements related to disputes/appeals on denied claims.  Will assist in developing and maintaining standardized processes related to individual payer requirements.  Assists in identifying denial root causes and communicates resolution to Management to correct any denial trends. 

MINIMUM QUALIFICATIONS

EDUCATION:  High School diploma or General Education Degree (GED) required.

EXPERIENCE:  Three (3) years of related experience, specific to role specialty such as medical billing or third-party collection, or customer service in a hospital, payer, or physician setting.  Technical experience in CMS/Medicaid regulations and/or commercial payer billing requirements.   Minimum three (3) years’ experience in a windows environment, including Excel.  Relevant professional certification encouraged within 2 years.

LICENSURE OR CERTIFICATION: None required.

KNOWLEDGE, SKILLS, AND ABILITIES:

·         Knowledge of medical insurance practices and policies and regulations.

·         Knowledge of HMO, PPO, and Indemnity third party billing guidelines (Third-Party Billing and Collections only).

·         Knowledge of either UB04 hospital or CMS physician billing forms (Third-Party Billing and Collections only).

·         Knowledge of government and non-government uniform billing guidelines (Third Party Billing only).

·         Knowledge of medical terminology and coding Related to hospital billing and/or professional billing such as revenue, CPT diagnosis codes, modifiers, occurrence codes, value codes, and the appropriate usage of these codes.

·         Skill in evaluating bills/claims for payers or patients in order to collect payment in a timely manner.

·         Skill in providing assistance or training to other staff members in a team environment.

·         Skill in the use of computer applications and systems including:  Excel, Word, Internet, email, and miscellaneous programs and networked computer systems.

·         Ability to read and comprehend instructions, short correspondence, and memos.

·         Ability to write correspondence; ability to effectively present information in one-on-one and small groups situations to customers, clients, and other employees of the organization.

·         Ability to read and interpret documents such as safety rules, procedure manuals, and governmental regulations. 

·         Ability to effectively present information and respond to inquiries or complaints from payers, patients and/or their representatives.

·         Ability to demonstrate familiarity of the components of a medical chart in order to supply appropriate chart documentation to various payers as required (Third Party Billing and Collections only).

·         Ability to identify any trends related to their assigned payer in order to escalate to management or provider representative (Third-Party Billing and Collection only). 

·         Ability to read and interpret payer explanations of benefit documents (Third-Party Billing and Collections only).

·         Strong analytical and critical thinking abilities in order to make sound decisions. 

·         Ability to demonstrate compliance with all state and federal regulations for managed care and third-party payers (Third-Party Billing and Collections only). 

·         Ability to handle higher complexity accounts.

·         Self-starter with ability to research independently.