Responsible for financial resolution of receivables by verifying appropriate reimbursement for services rendered. Achieves by persuasive collection techniques, problem solving, complex mathematical proficiency, resolving eligibility, insurance claims billing, insurance claim follow up and/or other related obstacles, according to the existing procedures for collection and by utilizing all available patient accounting and/or payor software.
- Has a thorough understanding of CPT, HCPCS & ICD-10 codes, HCFA and UB04 claim forms, DRG, insurance benefits including authorizations/referrals.
- Works daily with automated worklist, ATB and or assigned special projects in the patient accounting system to perform account audits of insurance and patient payments. Utilizes claims editing software and/or payor software to review claims history in order to address and resolve payment delays and/or incorrect payments.
- Maintains ability to read and comprehend all payors’ claims adjudication vouchers, explanation of benefits (EOB), or electronic remittance advice (ERA). Utilizes vouchers, EOBs, and ERAs to help confirm proper processing of claims and appropriate levels of reimbursement.
- Maintains a current and thorough knowledge of regulatory and procedural requirements related to the assigned account workload. Knowledge of applicable contracted payor documents including the contract matrix and state and federal regulations are required. Regulations include but are not limited to various reimbursement methodologies depending on the services billed and claims editing content.
- Contacts insurance companies or clients and uses proper negotiation or persuasion techniques to elicit payment promise or account resolution. When necessary, works with billers to perform re-bills or secondary billing. Calendars follow up collection calls and activities, according to existing procedures in order to meet personal productivity and departmental receivable goals.
- Performs appeals of insurance denials and/or incorrect reimbursement. Facilitates medical record documentation submissions when medical necessity is the basis for denial and other required documentation when expected reimbursement is not received.
- Processes all refunds, payment transfers and adjustments for account workload according to established Patient Financial Services (PFS) policies.
- Contacts patients when necessary to elicit claims and account resolution. Demonstrates good customer service and is knowledgeable when contacting patients.
- Identifies self-pay accounts and potential bad debt accounts for referral to outside agencies or attorneys for further collection efforts.
- Communicates regularly with PFS Supervisor or Manager regarding high-risk accounts.
- Responds timely (within 24 hours or next business day) to account inquiry calls from patients or insurance companies. Researches claims or account questions with responsible department and provides customers with requested financial information or refers them to other resources at National Jewish Health.
- Provides PFS Supervisor and reports weekly productivity statistics and reports workload fluctuations (backlog or shortages) in a timely manner. Maintains individual goals established by PFS management.
- Actively participates in team and departmental meetings by sharing ideas for improved work processes in PFS and performs as a back-up to staff absences and vacancies, as necessary.
- Accountability: Accepts full responsibility for self and contribution as a team member; displays honesty and truthfulness; confronts problems quickly; displays a strong commitment to organizational success and inspires others to commit to goals; demonstrates a commitment to Patient Financial Services Departments and National Jewish Health.
- Adaptability: Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.
- Attention to Detail: Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time. Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence rather than having standards imposed.
- Collaboration/Teamwork: Cooperates with others to accomplish common goals; works with employees within and across his/her department to achieve shared goals; treats others with dignity and respect and maintains a friendly demeanor; values the contributions of others.
- Decision Making: Identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints, and probable consequences.
- Drive for Results: Setting high goals for personal and group accomplishment; using measurement methods to monitor progress toward goals; tenaciously working to meet or exceed goals while deriving satisfaction from that achievement and continuous improvement.
- Managing Work and Time: Effectively managing one’s time and resources to ensure that work is completed efficiently. Effectively manages project(s) by appropriately focusing attention on the critical few priorities; effectively creates and executes against project timelines based on priorities, resource availability, and other project requirements (i.e., budget); effectively evaluates planned approaches, determines feasibility, and makes adjustments when needed.
Supervisory or Managerial Responsibility
- Be available to work as scheduled and report to work on time.
- Be willing to accept supervision and work well with others.
- Be well groomed, appropriately for your role and wear ID Badge visibly.
- Be in compliance with all departmental and institutional policies, the Employee Handbook, Code of Conduct and completes NetLearning by due date annually.
- Fosters an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the institution.
- Adheres to safe working practices and at all times follows all institutional and departmental safety policies and procedures.
- Wears appropriate PPE as outlined by the infection control policies and procedures.
- Demonstrates compliance with all state, federal and all other regulatory agency requirements.
High school graduate or equivalent required. Some college level course work, preferred.
A minimum of (2) years of recent and related healthcare collection or billing experience is required. A minimum of two (2) years in hospital billing/collection/follow up, accounting and customer service environment is preferred.
Special Training, Certification or Licensure