PURPOSE AND SCOPE:|
Supports FMCNA’s mission, vision, core values and customer service philosophy. Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements.
Under direct supervision, responsible for researching and responding appropriately to notifications of payment denials, underpayments, overpayments and no response claims related to reimbursement for services performed at the FVC center locations.
DUTIES / ACTIVITIES :
Responsible for driving the FMS and FVC culture through values and customer service standards.
Accountable for outstanding customer service to all external and internal customers.
Develops and maintains effective relationships through effective and timely communication.
Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.
PRINCIPAL RESPONSIBILITIES AND DUTIES
Ensures that all charges billed on behalf of FVC centers are paid accurately and within the required time parameters by identifying and taking the required steps to investigate and resolve payment denials and other payment issues.
Investigates and takes the appropriate steps to address and resolve payment denials and incorrectly paid accounts.
Reviews the Detailed Accounts Receivable (A/R) Aging report on a daily basis to capture “no response” claims and to follow-up or re-examine claims “with response” at least every 30 days until the account is resolved appropriately.
- On a daily basis, reviews the updated denial management log listing accounts that are denied, underpaid or overpaid. Researches the account listed in billing application, reviews the Explanation of Benefits (EOB) that specifies how the insurance carrier processed the claim and the reason for denial or incorrect reimbursement. Researches and resolves these claims issues contacting the pertinent parties by telephone or insurance website.
- Reviews patient Explanations of Benefits (EOB) including; approved amount, amount paid, denial codes, other information provided by insurance carrier related to payment or denial of benefits to determine if further investigation necessary i.e. if claim was denied.
- Ensures timely and accurate reimbursement by responding to the appropriate insurance carriers regarding:
- The denials with one or more of the following actions: - resubmitting corrected claim due to internal billing error, requesting claim reprocessing for insurance reprocessing error, submitting/resubmitting primary EOB, correcting patient demographic and/or insurance information, correcting Coordination of Benefits (COB) information, submitting appeal for missing authorization, and/or submitting appeals for medical necessity.
- incorrect payments with one or more of the following actions: - correcting COB information, requesting claim reprocessing per contract and surgical procedure reimbursement policies for insurance reprocessing errors, submitting/resubmitting primary EOB, requesting takeback or future claim offsets to resolve overpayments, preparing internal refund request with all EOBs, providing explanations for overpayment and any pertinent supporting documentation. All refund requests must be approved by AR Team Lead and a senior manager.
Works the accounts listed on the A/R aging report, which is generated and sorted each month by the A/R Team Lead position.
Meets productivity goals by working 95% of accounts for the assigned FVC Center within 45 days from bill date
Identifies payer-specific trends that cause an increase in the A/R aging. Generates selective payer aging reports as needed for the purpose of addressing A/R deterioration for specified payers. Updates the aging report with initials, date worked and next follow up date for each account worked for resolution.
Reviews the electronic data interchange vendor website (Navicure), for payer claim rejections – electronic claims that are flagged for incorrect or invalid information on the original electronic claim. Determines reason for rejection and identifies claim form locators causing the errors. Corrects information submitted internally causing the rejection and resubmits claim. Escalates issues to A/R Team Lead or supervisor; or submits “tickets” to Navicure to further investigate rejections that are unclear.
Generates and disseminates monthly patient statements per the established procedure.
Determines if insurance adjustments are due according to particular qualifying criteria/reasons specified in the Standard Operating Procedures and makes the appropriate insurance adjustment request with the relevant documentation to the A/R Team Lead or Supervisor.
- Issues first patient statement within one week of determining patient liability.
- Issues second statement within 30 days from the issue date of the first statement.
- Issues letter within 30 days of the second statement indicating attempts to contact patient and options for assistance.
- Follows up with telephone call to patient.
- If no response, proceeds with bad debt write off request, unless otherwise specified by FVC center location obtaining the required management approvals.
Updates Medical Manager or Imagine with notes to reflect account status and collection activity.
Provides timely communication to Team Lead and other management personnel with regards to payer issues and updates.
Other duties as assigned.
PHYSICAL DEMANDS AND WORKING CONDITIONS:
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Prolonged sitting at a computer work station. Extensive use of telephone and ability to maintain a focused train of thought while multitasking in the process of investigating billing issues. Able to concentrate on detail oriented data for prolonged period of time. Able to adjust routine to accommodate departmental needs and goals; must be able to lift light objects; retrieve files from cabinets which may involve upward or downward physical mobility; can focus on computer monitor for prolonged periods and clearly see data in paper form with small font printing; can effectively communicate via telephone.
High School Diploma or GED.
EXPERIENCE AND REQUIRED SKILLS:
1-2 years medical billing or collections required with HS Dip/GED. 0-1 with a 2 or 4 year degree.
Strong mathematical aptitude. Payment applications experience in a healthcare environment is helpful.
Strong knowledge of Windows-based software applications. (Eg: Word, Excel…)
Excellent written and verbal communication skills.
Strong organizational and time-management skills.
Attention to detail.
Positive attitude and team-oriented approach.
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