Responsible for submitting accurate claims, ensuring timely reimbursement from various third-party payers and patients, and confirming proper documentation occurs in the facility’s billing system. Collaborates with Revenue Cycle departments and third-party payers on efforts related to follow-up, denials, and appeals.
ESSENTIAL DUTIES AND RESPONSIBILITIES: include the following:
Examines denied and underpaid claims to determine reasons for discrepancies.
Communicates via phone calls and web-portals, directly with payers to follow up on outstanding claims, resolves payment variances, and achieves timely reimbursement.
Provides payers with specific reasons for suspected underpayments and reviews denial reasons given by payers. Documents patient account (HAR) with status and expected payment amounts.
Works with management to identify, trend, and address root causes of denials; helps pinpoint strategies for reducing Accounts Receivables (A/R).
Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliance issues and payer discrepancies.
Keeps current using payer bulletins, coding and billing training and manuals.
Updates and maintains accurate files on each payer, including contact names, addresses, phone numbers, and other pertinent information. Notifies PFS managers of changes to update other TFH Departments.
Thoroughly documents all interactions with payers.
Handles all payer-specific communications, including telephone and email, from payers and departments within the business office.
Participates in quality improvement efforts on an ongoing basis. Strives to exceed goals established with leadership, typically working a minimum of 40 – 50 accounts per day.
Demonstrates initiative and resourcefulness by gathering information and examples about issues and helping to document recommendations for system fixes.
Communicates trends and issues to management and helps to monitor and validate fixes.
Understands and maintains compliance with HIPAA guidelines when handling patient information.
Performs other duties as assigned.
Demonstrates System Values in performance and behavior.
Complies with System policies and procedures.
EDUCATION AND EXPERIENCE: High school diploma or general education degree (GED). Minimum of two years recent billing and follow-up experience in hospital and/or physician clinical areas required. Preferred: Prior experience in Medicare or Medi-Cal (Medicaid) billing, EPIC Hospital Billing and/or Physician Billing.