Patient Financial Services Rep II

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. Requires working knowledge of the Revenue Cycle and the importance of evaluating and securing all appropriate financial resources for patients to maximize reimbursement to the health system. Serves as contact for Patient Financial Services Representative, Level 2 regarding questions/account issue resolution. The PFS Representative, Level 2 must have knowledge of at least one specific payer’s application, billing and/or collection process.  This position assumes the clinical and financial risk of the organization when collecting and documenting information on behalf of the patient. The PFS Representative, Level 2 works directly with customers, physicians, and payer representatives to provide information and resolve issues in a highly responsive manner. The PFS Representative, Level 2 must complete all initial and annual training relevant to the role and comply with all relevant laws, regulations, and policies. 

Process 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 be transferred to the appropriate payer workgroup or until the account is deemed to be self-pay and referred to the self-pay collectors.
Identify problem accounts and work towards a timely resolution.
Assists in continuously improving the aging of receivables while minimizing controllable loss categories.
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.
Screen claims online or on paper for accuracy and obtains additional information for processing claims manually or via a computerized system.
Performs post review of all payments applied to assigned accounts to ensure payments and discounts are in compliance with regulations, guidelines, and/or policy.
  Customer Service 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.
Communication Serves as contact for others regarding questions/account issue resolution.
Mentors and trains other staff.
Other Takes personal accountability for professional growth and development.

EDUCATION: High School Diploma required; business or technical school completion or Associate Degree preferred.
LICENSURE, REGISTRATION, CERTIFICATION: N/A  
EXPERIENCE: At least twelve (12) months of experience as a Patient Financial Services Representative I or equivalent position within the Revenue Cycle or two (2) years of immediately applicable experience in medical billing and collection or medical coding required.