JOB SUMMARY: This position is responsible for Biling, Re-Billing, Post-payment and Account follow-up and/or grievance preparation of assigned Client Hospital Accounts Receivable. Working at a Client site or in a Centralized location, responsibilities may include account maintenance of specialized or multiple payers including state and federal government programs, managed care, commercial and other insurance groups. The Patient Account Specialist may serve as a liaison to clinical auditors, other team members, hospital staff, government agencies and health plans to facilitate the appropriate and prompt payment of claims. This individual must demonstrate a commitment to the organization's strategic plans, short and long term goals and mission, vision and values by representing the company in a caring and professional manner.
Primary / Essential Functions:
The Primary/ essential job duties may not be exhaustive.
Effectively and efficiently performs essential job duties.
- Reviews and/or scrubs final billed initial claims for accuracy and completeness before submitting for payment
- Obtains necessary patient records required as attachments to claims
- Calculates Tier, Outlier, DRG and/or other Fee Schedule based reimbursement
- Submits electronic and/or hardcopy claims with any attachments as per the contract timely filing criteria
- Documents all account activity in the hospital system notes and the database
POST PAYMENT REVIEW
- Within appropriate time frames, contacts the health plan by phone or website to determine status of claim
- Documents all follow-up actions in the hospital account notes and database and sets up account for additional review based on client expectations for follow-up of unresolved accounts
Physical / Mental Demands, Environment:
- Researches all account information on paid or partially paid claims and analyzes the status of the payment related to the expected payment calculation and itemization provided by the remittance advice
- Determines if payment is appropriate according to contract specifications
- Analyzes any denied, disallowed or non-covered claims and determines if non-payment is based on medical or technical reasons
- Resolves any technical issues when warranted with health plans via phone or website
- Prepares requests for account balance adjustments in accordance with client specific procedures
- Prepares claims for clinical audit processing in the case of authorization, coding, level of care and/or length of stay denials
- Processes overpayment transactions in accordance with client specific procedures
- Follows guidelines for prioritization, timely filing deadlines, hospital and database documentation
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions, recognizing that Adreima must work within the limitations established by the client when working on-site.
- Must be able to use hands to finger, handle or feel, sit, stand, walk, lift up to 20 pounds, stoop, clean, bend, and reach with hands and arms.
- Must communicate clearly in English. Requires the ability to speak, read, write, see, and hear to perform essential duties of the job.
- Effective and positive human relations skills are required, including confidentiality, in order to appropriately interface with staff, patients and their families.
- Must be able to perform multiple tasks and detailed work, problem solve, reason, and perform basic mathematical calculations.
- Knowledge and skills typically acquired through receipt of a diploma
- Requires a minimum of five years of related job experience
- Experience in the health care field or with a health care services related business
- Working knowledge of computer programs and technical applications
- Excellent verbal and written communication skills are essential
- Strong organizational and coordination abilities are required
- Must have experience with Medicare billing
Adreima specializes in assisting hospitals maximize reimbursements while decreasing demands on in-house staff. Our Receivables Management...