THIRD PARTY BILLER - South Shore Health

Job Description Summary

Accumulate data from Patient Access and Health Information Management for the purpose of submitting compliant third party insurance and physician claims. Initiate all collection calls for payment on aged accounts receivable up to the point of self-pay collections. Generates reports for responsible insurance plans and maintains online collection worklists and online claims editing software for maximum efficiency. Ability to decipher reimbursement schemes for assigned insurance’s to complete the revenue cycle

Job Description

1. Maintains up to date knowledge of all Federal, State and Insurance specific billing regulations, policies, procedures and code sets. Retains knowledge of Hospitals Credit Collection Policy.
a. Notifies manager of any changes that would effect claim submission

2. Evaluates daily claim file using online claim editing software for submission of UB92 and 1500 claim forms.
a. Initiate claim corrections as defined by insurance regulation and hospital policy.’
b. Evaluate unresolved accounts weekly, contact outside departments as needed and submit status to manager weekly to resolve unbillable accounts.

3. Initiate collection of aged accounts receivable through an automated collector work lists.
a. Unresolved accounts require insurance company contact by phone, e-mail or designated web site to resolve outstanding balances.
b. Collaborate with denial management staff for accounts than require clinical intervention for an appeal process.
c. Generate technical appeals as needed for account resolution.
d. Provide to manager a detail account history for any account that is considered uncollectable.
e. All work list accounts must have collection efforts documented every 30 days unless otherwise notified.
4. Generate reports as needed for collection of aged accounts receivable.
a. Accumulate at the beginning of each month or as requested a listing of unresolved/open accounts with aging greater than 120 days for manager review.

5. Evaluate insurance reimbursement schemes as needed to verify that payments and adjustments have been accurately recorded.
a. Review credit balance accounts in assigned worklist, review payment history for accuracy. Make a determination if a refund is needed and forward to the appropriate refund agent for resolution.
b. Initiate Insurance retractions as needed for payments posted to the Hospitals Unlocated Cash Accounts. Incorrect payments that require a check will be forwarded to the appropriate refund agent for resolution.
6. Communicate with patients as needed for additional insurance or other information needed in order to process a claim.
a. Generate phone calls or letters as needed to obtain necessary insurance or other related information, prior to an account being placed in self pay.
b. Obtain proper verification of predefined patient demographic information and maintain documentation in order to verify identity.
7. Technology – Embraces technological solutions to work processes and practices.
a. Uses the API payroll system to enter time worked, sick days, vacations and holidays.
b. Uses Meditech to access and run reports.
c. Uses Lotus Notes as a communication tool.
d. Access provider web sites for verification of accounts.
8. Safety Awareness – Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.
a. Successfully answers safety questions in the annual mandatory education packet.
b. Maintains a neat, organized work environment.
c. Adheres to respiratory etiquette guidelines.

Non-Essential Functions

Non-essential functions are those tasks, duties and responsibilities that are not critical to the performance of the job. Following are the non-essential functions of the job, along with the corresponding performance standards.
1. Other duties as required.
2. Attends and participates in staff meetings, in-service meetings and other activities as related to job performance.
3. Attend seminars, workshops and training sessions offered by providers.

Age Related Competencies
Does this employee provide any patient care related services? Yes _____ No __X__
Organizational Competencies
Following are the organizational competencies and corresponding performance standards for all employees in the organization. Indicate how the employee performed relative to these standards by checking the appropriate boxes.
Service

The extent to which an employee demonstrates an understanding of the organizational and department’s service standards and strives to achieve them, treats patients and families with dignity, compassion and respect at all times, and demonstrates courtesy in interactions with members of all departments and disciplines within the Hospital.
Teamwork

The extent to which an employee acts as a cohesive member of a work team and demonstrates appropriate interactions with all Hospital service providers.
Communication

Fosters an environment that nurtures collaboration, teamwork and mutual respect through effective communication, and demonstrates positive communication skills evidenced by effective working relationship.

Respect For Others

Takes actions that indicates a consideration for others and awareness of the impact of one’s behavior on others, demonstrates respect for diverse backgrounds of all patients, families, and co-workers, and seeks accommodations.
Time and Priority Management

Optimizes use of time by efficiently using resources to identify barriers and balance priorities. Efficiently utilizes tools, resources, techniques and/or systems to organize tasks. Balances multiple priorities simultaneously, assuring the timely and accurate completion of each task, while maintaining quality standards.
Quality Awareness/Performance Improvement

The extent to which an employee demonstrates an understanding of their role in maintaining a commitment to quality. Quality is the consistent provision of safe, effective and satisfying care and services.
Safety Awareness

Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. (Department and/or individual performance standards may also be addressed in essential functions of position.)