Under minimal supervision by the Director of Patient Accounts (or designee), this position is responsible for performing billing and collections, verifying insurance eligibility and covered services, as well as possessing an understanding of billing rules and compliance, regulations, and maintaining knowledge of the Hospital’s patient accounting systems. These skills are necessary to bill and collect the correct payment for the services provided by the Hospital. Responsible for account management functions such as claims and payment research, claims corrections, rebills, and making phone calls to resolve unpaid claims. Skills to perform these functions are expected from the incumbent to be present and maintained through internal and external ongoing education.
NATURE AND SCOPE:
Interacts regularly with internal peers, staff and management from other revenue cycle functional areas, administrative/medical/executive management, patients and their family members, as well as Hospital and University officials, healthcare providers and the general public.
Interacts regularly with external government agencies, insurance carriers, attorneys, vendors and healthcare providers.
- Review and update patient accounts insurance information and ensuring third party payor information is complete and accurate.
- Enters/Updates patient, insurance, contract, revenue and/or reimbursement data into one or more Siemens computer system, Medicaid Portal, Medicare Portal, and MCO Portals and accounts receivable information daily.
- Prepares and submits hardcopy billing claim packages, including collecting of all necessary materials for proper claim creation/modification; making payor specific data changes as required for accurate and timely billing.
- Collects all necessary materials for accurate claim creation, submission and timely adjudication; makes payer and patient demographic changes to system data as required for accurate and timely billing; monitors claims submissions, follow-up activity and secondary claim processing; Verifies that payments and account balances are correct and compliant with payer contracts and billing rules and regulations.
- Contacts insurance carriers as scheduled by collection tool. Inform the insurance company of an action plan if there is a delay in resolving account for adjudication.
- Identify review and resolve denied claims daily. Monitor status of patient accounts and accounts receivable information using the Siemens computer system, Medicaid Portal, Medicare Portal, Carefirst, and MCO Portals
- Utilizes HUH payer contracts to effectively & efficiently calculate expected reimbursements.
- Performs routine arithmetic calculations associated with revenue billing, computing expected payor and patient reimbursement amounts, as well as contractual adjustment amounts for individual accounts.
- Establishes and/or monitors self-pay finanical plans; working with vendors as necessary where patients may qualify for financial assistance.
- Performs all necessary claim review and research to prevent claim delay as required for accurate and timely billing.
- Reviews claims having incorrect or missing patient data, facilitates in the correction/addition of missing account data for the purpose of submitting an accurate and timely claim; subsequently initiates and follows through on remedial actions with supervisor to develop solutions that prevent future occurrences when errors are identified as being chronic.
- Review and correct claim errors occurring on electronic claim scrubber system as defined by departmental guidelines; Monitor error frequency with immediate supervisor as remedial actions are developed and executed with error’s root cause.
- Reviews and corrects all necessary items reflected in electronic billing/rejection reports or online claim status query results, delaying a third party payor’s processing of claim(s); Subsequently initiates and follows through on remedial actions with supervisor to develop solutions that prevent future occurrences when errors are identified as being chronic.
- Reviews and resolves credit balances accurately; Monitoring and reporting to immediate supervisors concerns with out-of-the-ordinary circumstances for investigation.
- Performs payor remittance to reimbursement posting reconciliation and reimbursement posting corrections; ensuring reimbursement consistent with payor contractual/agreement terms before performing adjustments and/or billing of patient responsibility.
- Performs manual posting of payments and necessary research when electronic posting is not applicable. (i.e. lock box, payment posting batch failures, unidentified payments.)
- Receives and responds timely to internal/external phone calls, correspondence, and inquiries related to patient accounts.
- Performs internal/external phone calls, drafts correspondence, and makes inquiries related to account(s) as required for accurate and timely billing.
- Prepares and maintains supportive data and documents on all required activities within hospital system as defined by departmental guidelines.
- Assumes other duties and responsibilities that are related and appropriate to the position and area.
- The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
- Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
- Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
- Participates in activities that promote adherence to federal healthcare program requirements.
- Actively participates in Health Sciences Compliance Program activities.
- Adheres to the requirements of the HIPAA Privacy Policies and Procedures.
- Maintains confidentiality of patients, families, and staff.
- Ability to meet or exceed established productivity standards as defined by management and/or departmental guidelines.
- Demonstrates the ability to consistently meet or exceed principle accountabilities required of this position.
- Consistently demonstrates ability to produce accurate Medicare, Medicaid & Commercial payer claims that produce substantiated reimbursements.
- Ability to assemble, analyze, comprehend, copy, record and/or transcribe data and/or information according to universal practices.
- Knowledge of standard hospital organizational structure and roles departments play in day-to-day operations.
- Ability to initiate an exchange of information for the purpose of obtaining information and clarification of details.
- Ability to start, stop, operate and monitor the functioning of information systems, equipment, machinery, tools, and/or materials used in performing essential functions.
- Ability to perform addition, subtraction, multiplication, and division individually and in conjunction with each other; Calculate decimals and percentages.
- Ability to carry out instructions furnished in written, oral and/or diagrammatic form, aptitude for deductive reasoning leading to predictable outcomes.
- Ability to exercise the judgment, decisiveness and creativity in situations involving a variety of pre-defined duties which are often characterized by frequent change.
- High proficiency in the use of Invision, Aurora, Aegis, Patient Accounts and EDM profiles, SSI and Third Party Payor online resources. Proficiency in the use of Microsoft Office programs including but not limited to: Outlook, Excel, and Word.
- Ability to make a great first impression and to maintain ongoing positive relationship with customers; recover from service failures timely and professional manner.
- Competence in both oral and written English.
- Ability to establish and maintain effective and harmonious work relationships with staff, physicians, Hospital and University officials, and the general public.
- The employee is expected to achieve appropriate Hospital performance and productivity standards as established.
- The employee will perform other duties that further the customer service needs of the department, such as answering phones, greeting and escorting patients, and administrative and clerical duties upon deman
- Must demonstrate collaboration; accountability; respect; excellence; and service.
- Works with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors; looks for ways to achieve departmental/institutional results by partnering.
- Accepts responsibility for his/her actions to provide health care and or ancillary functions in a highly efficient and compassionate manner. The employees must function as a Steward (Have Ownership) of the Howard values that foster a commitment to improving the patient and student experience, organizational efficiency and environment.
- Embraces diversity; cares holistically for those we serve; treats all as we would like to be treated; manages the patient’s right to privacy with meticulous care 100% of the time and keeps patient and proprietary information about the institution confidential.
- Anticipates the patient’s and student’s needs, presents as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experience for our customers.
- Behaves in a friendly, resourceful and professional manner towards all they encounter; treats patients, students and visitors in the same way that they would want their family members or themselves to be treated.
Must be able to walk, sit, lift (12-25lbs), reach, handle, write, type, speak, hear, see (depth perception), calculate, compare and evaluate, for extended periods of time.
- High School Diploma or General Equivalency Diploma (G.E.D.)
- At least five years of experience in billing and collections required, hospital environment preferred and should be able to pass the Patient Financial Services Proficiency Test by 80% or more; OR Possess and retain throughout employment certification as a Certified Patient Account Representative – CPAR (HFMA) or Certified Revenue Cycle Specialist (CRCS-I (AAHAM)).