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. This
position requires a basic understanding of the Revenue Cycle and
the importance of evaluating and securing all appropriate financial
resources for patients to maximize reimbursement to the health
system. This position assumes responsibility for collecting and
documenting information on behalf of the patient.
Additional responsibilities include notifying the patient and/or
guarantor of liabilities, verifying insurance benefits, and
assisting customers regarding billing questions. Focus on customer
service and process improvements are critical to this position, as
are communication and conflict resolution skills. The PFS
Representative, Level 1 must complete all initial and annual
training relevant to the role and comply with all relevant laws,
regulations, and policies.
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 claims 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
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.
Screens claim online or on paper for accuracy and obtain additional
information for processing claims manually or via a computerized
Performs post review of all payments applied to assigned accounts
to ensure payments and discounts are in compliance with
regulations, guidelines, and/or policy.
Ensures that incoming call volumes are processed expeditiously and
communicates effectively in all patient interactions.
Conducts in-person patient interviews for customer service
Ensures that incoming correspondence is processed
Ensures that all written responses are clearly and professionally
Serves as contact for others regarding questions/account issue
resolution. Mentors and trains other staff.
Takes personal accountability for professional growth and
High School Diploma required.
LICENSURE, REGISTRATION, CERTIFICATION:
1-2 years of healthcare or related experience preferred.
Knowledge of medical billing and collections or other financial
policies and procedures and must possess the ability to perform
medical billing, collection, or customer service functions as
normally acquired through related work experience or the equivalent
of three (3) months of on-the-job training.