Patient Financial Services Rep I - (Customer Service)

Patient Financial Services Representative, Level 1

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 payments and or rejections and properly account for payment and adjustments.
• Identifies account overpayments, determines payer source to be refunded, and initiates refund requests. Works with the department management, Compliance Department, and/or other organizational resources to determine if refund requests are valid. Refunds audited governmental payer claims promptly.
• Prepares periodic credit balance reports for the assigned ledger in accordance with defined procedures.
• Attends in-services, classes, and meetings related to job functions to include mandatory annual Billing and Coding Compliance training in accordance with the WTH Compliance Plan.
• Works closely with department management and hospital departments to identity and resolve billing and collection issues. Identifies trends in billing and collection activity and reports any observed or suspected deviation from policies or from Medicare, Medicaid or other insurance regulations immediately to the department management.
• Investigates and responds to questions or requests for additional information from patients/guarantors, attorneys, and all other authorized parties in a timely and professional manner.
• Utilizes systems, tools, and department resources to achieve production and quality targets for resolution of patient accounts.
• Demonstrate proficiency in at least one or more of the following: Billing processes of at least one specific payer's billing and collection practices; Account Follow-Up processes of at least one specific payer's billing and collection practices including credit balance resolution; Denials management processes to include denial/claim research, filing appeals, and resolution of denied patient accounts; Payment Posting and Cash Reconciliation processes; Self-Pay Processing / Customer Service including qualifying accounts for charity care, bad debt, and credit balance resolution.
• Ensures data integrity for the generation of patient statements, letters, and other correspondence.
• Initiates, reconciles, and maintains collection agency assignment of accounts meeting bad debt status. Completes placement and balancing reports for the bad debt ledger and monitors daily bad debt recovery and adjustments. Charges back accounts to active A/R from bad debt status as necessary.
• Posts cash to accelerate cash flow including all necessary related data entry functions. Identifies appropriate patient accounts to credit for every payment received. Contacts payer sources for research of unidentified payments. Initiates, performs, and reconcile electronic remittance posting processes.
• Batches cash source documents into groups, totals and balances each batch, completes batch sheets for data entry. Identifies non A/R and bad debt payments, batches separately and coordinates the application of the payment with accounting by obtaining and applying the correct general ledger number, completing a transfer form, and logging the transfer to be sent to the appropriate department.
• Provides oversight to other representatives to ensure quality and efficiency of functions performed.
• Gathers data, summarizes and prepares reports for management and completes special projects as assigned.
• 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.
• Notifies patient and/or guarantor of insurance Explanation of Benefits to patients, including deductibles, co-pays, coinsurance, non-covered expenses, denials, and additional information needed; assists patients with follow-up to insurance carriers for account resolution.
• Assists customers regarding billing questions and ensures appropriate resolution of problems. Explain and interpret eligibility rules and regulations or identify other resources available for financial assistance. Keep updated on changes with regulatory issues.
• Assesses financial information for patients that are unable to pay balances in full and establishes payment plans in accordance to defined standards.
• Serves as contact for others regarding questions/account issue resolution. Mentors and trains other staff.
• Communicates daily via the telephone or written communication with payers, patients, departments to obtain and provide all information for payers to process and pay claims quickly and accurately.
• Works with other departments (e.g. PAS, HIM, Case Management, etc.) to appropriately contribute to account resolution and manage receivables.
• Takes personal accountability for professional growth and development.
• Performs related responsibilities as required or directed.

Job Specifications:

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.

Knowledge, Skills and Abilities:

• Requires basic knowledge of accounting principles and general office procedures, including healthcare revenue cycle operations.
• Ability to understand basic knowledge of principles that directly impact the accounts receivable, including debit