PFS Representative II

SUMMARY:

Performs self-pay collections or third-party billing/collections which includes a complex review of billing and collection activities. Resolves problems and demonstrates complete understanding of payer and/or patient requirements to ensure timely and accurate payment. Makes independent decisions based on the needs of the patients and/or payer situations.

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.
• Performs related duties as assigned.

Third Party Billing and Collections: Performs third party billing and collections functions which includes a complex review of billing and collection activities. Resolves claim edits and demonstrates complete understanding of payer claim requirements to ensure timely and accurate payment. Ensures timely and proper reimbursements by researching and resolving all aged receivables.

Self-Pay Collector: Performs self-pay collections which include complex review of billing and collections activities. Resolves and researches any potential coverage to ensure timely and accurate payment. Has a complete understanding of all options to resolve the balances. Processes payments, sets up payment arrangements, and offers financial assistance to patients who are experiencing financial difficulty. Must exhibit strong knowledge of fair debt collections. Meets with patients/families to acquire payment options or complete financial applications for all special programs available to resolve accounts; evaluates accounts and determines payment dates based on patient's ability to pay and hospital policies; explains charges, services, and hospital privacy regarding payment of bills. Provides back up phone support for the Customer Service team. Provides technical assistance to set up MyChart access. Works assigned work queues in a timely manner.

Customer Service: In a high call volume setting, performs self-pay collections which include complex review of billing and collections activities. Resolves and researches any potential coverage to ensure timely and accurate payment. Has a complete understanding of all options to resolve the balances. Processes payments, sets up payment arrangements, and offers financial assistance to patients who are experiencing financial difficulty. Evaluates accounts and determines payment dates based on patient's ability to pay and hospital policies. Must exhibit strong knowledge of fair debt collections. Explains charges, services, and hospital privacy regarding payment of bills. Provides technical assistance to set up MyChart access, and answers inquiries submitted through MyChart. Works assigned work queues in a timely manner.

Payment Poster The Poster must demonstrate a thorough understanding of all aspects of payment posting and the explanation of benefits key data and employ standards of best practice to ensure all balancing procedures and documentation guidelines are met. The poster is responsible for posting payments both electronically and manually. Receives, reviews, organizes, and accurately post payments to the appropriate patient account. Attaches necessary documentation. Adjusts charge balances in accordance with Payer Explanation of Benefits (EOB) and Provider Contracts prior to posting. Correctly calculates adjustments and posts these to the accounts as well. Researches unidentified cash, resolves misdirected payments and verifies that adjustments. Communicates with insurance companies, state agencies AHCCCS/Medicaid, and vendors to research outstanding payments and to retrieve EOBs.

Denials Support Representative: Performs routine reviews and reconciliation of non-clinical denied commercial and Medicaid claims. Assists in communicating with insurance companies regarding claim denials. Submits corrected claims or initiates appeals under guidance. Works under supervision to resolve issues and applies knowledge of payer requirements related to disputes and appeals. Supports the development and maintenance of standardized processes by following established procedures. Helps identify denial trends and reports findings to Management for further action.

MINIMUM QUALIFICATIONS

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

EXPERIENCE: Two (2) 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 two (2) years' experience in a windows environment, including Excel.

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).