Job Description

Responsible for collecting assigned accounts in a professional and timely manner. Works with Insurance companies and other payors to resolve accounts efficiently. Must be able to multi-task and have knowledge of contract language. To review EOB’s (Explanation of Benefits) for correct reimbursement. Must document and identify underpayments or overpayments. Submit appeals for the underpaid amount and process adjustments in an accurately, and timely manner. Must document overpaid accounts in the system for the Refund analyst final review. To ensure financial classes and/or I/Plans are changed to the appropriate payor. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Functions:

• Demonstrates competency and complete understanding of Managed Care insurance billing, collections, and contracts.
• Responsible to review EOB’s for correct reimbursement, documents underpayments and overpayments, Appeal underpaid accounts and prepares contractual adjustments.
• Maintains Contracts with appropriate reimbursement information as well as correct payor codes.
• Follows up on all accounts after billing until payment is received.
• Reviews and follows up on aged accounts with documentation in an efficient and thorough manner with accuracy.
• Ensures appropriate phone calls/or website status towards resolution on each account.
• Ensures re-bills to payors as needed and change update to correct plan IDs.
• Prepares appeals on denials and underpayments.
• Mails follow-up letters to patients/ insurance companies as needed.
• Consistently exercises sound judgment in arranging account settlement plans.
• Prepares accounts settlement options in a clear and persuasive manner.
• Works accounts on work ques/reports provided, averaging a minimum of 35-45 per day.
• Opens and reviews all financial/Paragon systems for proper account review (One content, payer Portals/websites and IPAS.
• Handles all clients in a courteous and professional manner.
• Ensures contractual/discounts are applied to accounts as specified in each contract.
• Refers an account to a biller and forwards a copy of the primary carrier’s EOB if a secondary insurance is applicable.
• Follows up on all correspondence requiring action as needed.
• Retrieves Patient records from the HBF system as needed.
• Demonstrates the ability to recognize and deal with priorities in order to complete work in a timely manner.
• Reviews all Managed Care Capped accounts prior to contractual write off.
• Works effectively with Hospital Contracts Management to resolve contract issues.
• Monitors contracts and Explanation of Benefits to ensure proper calculation and payment processing.
• Demonstrates competency when reviewing EOB’s for Managed Care Medi-Cal HMO’s according to Medi-Cal State HCPCS codes and fee schedule reimbursement.
• Responsible for reviewing EOB’s for correct reimbursement, documents underpayments and overpayments. Appeal underpaid accounts and prepares contractual adjustments.
• Knowledge in billing claims thru E-Premise/Relay Clearance systems.
• Responsible to reclassify Managed Care accounts as per EOB’s received.
• Performs all other duties and special projects as assigned.
• Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
• Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
• Completes and attends monthly training assigned.

Behavioral Standards:

• Exhibits customer and service-oriented behaviors in everyday work interactions.
• Demonstrates a courteous and respectful attitude to internal workforce and external customers.
• Communicates accurately and appropriately.
• Works well and efficiently under minimal supervision.
• Handles difficult situations in a discreet and professional manner.
• Is adaptable to changes in assignments and priorities.

Communication/Knowledge:

• Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.
• Provides accurate and timely written and verbal communication of information in a manner that is understood by all.
• Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
• Able to use IT systems in an accurate and proficient manner.

Collaboration/Teamwork:

• Contributes toward effective, positive working relationships with internal and external colleagues.
• Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization

Qualifications/Experience:

• At least two (2) to three (3) years of current experience in an acute care hospital setting, preferred.
• Knowledge of Contracts.
• Computer Skills required.