PFS Specialty Group Representative 1

• Research and preform audits on patient accounts to determine balances are being billed to the correct payer.
• Thorough understanding of how to identify if charges on a patient's account are correct. In depth understanding of what information is available to assist in the process, such as the medical records, chart view, MPI, etc.
• In-depth understanding of collection laws pertaining to worker compensation and third party liability claims.
• Become fluent and knowledgeable in the Single Billing Office environment within Epic
• Maintains a working knowledge of common billing and account resolution practices and requirements for hospital and/or clinic billing (SBO).
• Knowledge of how to work a claim from beginning to end
• Learn and create in-depth knowledge of all applications used by Patient Financial Services partners such as: Epic, Agility, Connex, Kronos, OneSource, Microsoft Word, Microsoft Outlook, Claim source, On-Base, etc.
• Identifies the correct filing order per department processes when multiple insurances are involved
• Responds to inquiries from patients, insurance companies, attorney offices and outside vendors via mail, phone and/or email.
• Responds to inquiries regarding credit balances on Workers Compensation, Third Party Liability, Hospice, Skilled Nursing Facilities and Occupational Health accounts and initiates the refund process in the event monies are due back to the payer or patient.
• Responds to Billing reviews/ inquiries from other PFS groups such as Billers, Follow-up, Cash posting and Customer Service.
• Documents all encounters on appropriate patient account/claim utilizing notes. Ensures account is updated to accurately reflect the current status.
• Protects privacy and confidentiality of customers, patients and partners in accordance with Mercyhealth policies, the Code of Ethics and HIPAA laws.
• Review all Work Comp, TPL and personal injury settlement requests before sending them to the Supervisor.
• Work special projects and other job duties as assigned
• Verifies claims are received by the payer and follows up to obtain payment via phone calls, portal or websites.
• Reviews failed claims, resolves disputed and denied claims.
• Obtains and sends medical records as needed for Workers Compensation claims, Third Party Liability accounts and attorneys' offices.
• Drafts appeal letters when applicable based on payer requirement in a format that is legible and relates to the denied claim.
• Become familiar with ICD-10, CPT, and/or HCPCS Coding Systems as well as claim forms such as CMS-1500 and UB-04 as well as payer remittances.
• Calls patients, payers and attorney offices without hesitation to obtain needed information to resolve account balances.
• Identify trends with payer denials and escalates these trends to leads/supervisors.
• Works with appropriate revenue cycle staff when performing account resolution functions.
• Responsible to work assigned work queues, reports and spreadsheets.
• Participate in department meetings, workgroup meetings, and training sessions.
• Ability to adapt to change in a positive, sensitive and forward-thinking manner in demanding situations
• Maintains productivity standards as outlined in the Revenue Cycle department

To perform the job successfully, an individual should demonstrate the following behavior expectations:

Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.

Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.

Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.

Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

*High school diploma or equivalent
*Microsoft Excel required and healthcare billing experience preferred.
*Undertakes self-development activities.
*Basic understanding of working in multiple software applications at the same time.
*2 - 3 years customer service experience preferred or 1 year customer service in medical field preferred.

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The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is frequently required to sit. The employee is occasionally required to stand; walk; climb; or balance and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

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