Under the direction of the Supervisor, Professional Billing & Coding, follows Federal, State, and local regulatory collection guidelines as well as payor specific billing/collection guidelines. Responsible for the collection of outstanding balances from all Commercial, HMO, PPO, Medi-Cal and Managed Care payors’ professional claims. Responsible for identifying follow up issues, checking status of unpaid claims by telephone, websites and/or any other means available. Responsible for providing information and documentation to ensure timely and accurate reimbursement. Manages and assembles all data and documents required for accurate follow-up of claims. Ability to perform complicated mathematical calculations to adjudicate accounts appropriately. Ability to analyze and adjudicate complicated contractual arrangements as determined by contractual agreements entered into by the MPF. Reviews remittance codes from EOB’s and R/A’s to ensure appropriate payment or to identify denials or non-payment. Responsible for follow up with payor on the routing of claims. Refers all payor issues/problems to leadership in a timely manner with specific examples. Responsible for complete, accurate, and timely documentation of all follow up pertaining to the resolution of the account within the IS system patient financial record. Responsible for daily processing of assigned work queues following standards established by Sr. Leadership. Appeals denied claims in a timely manner with concise, accurate and articulate information. Explores all options to secure payment when a denial is received. Performs root cause analysis on identified trends causing delays in resolution of outstanding claims. Responds to insurance requests and correspondence in a timely and professional fashion. Responds to patient inquiries and requests from management, co-workers and other departments in a professional, courteous, timely and proactive manner to remedy concerns and facilitate the billing process. Logs into the department phone system following department policies and procedures.
High School, GED or foreign equivalent
Three years of experience
Four years of experience
HR Use Only:
Rady Children's Hospital San Diego - 24 months ago