PATIENT ACCOUNT SERVICES REPRESENTATIVE

GENERAL PURPOSE:

Patient Account Services Representative is responsible for the revenue cycle management of a claim for all payer sources. This includes reviewing claims prior to billing based on established system edits. After initial billing it includes, monitoring, correcting and re-billing claims for Medicare, Medi-Cal, Managed Care, Private Insurances, CHDP, Family Planning, EWC, Private Pay, and Sliding Fee patients until the balance of the claim is zero.

MAIN RESPONSIBILITIES AND DUTIES:

1. Review claims prior to billing that require manual intervention, based on specific criteria for that payer source to include Medi-Cal, Managed Care, Medicare, CHDP, Family Planning, EWC, private insurances, sliding fee and self pay.
2. Print secondary claims, attach EOB for any payer who does not accept electronic secondary's.
3. Check the patients eligibility when reviewing pre-billing for established edits related to eligibility and for claims denied due to eligibility.
4. Reviews all manuals, updates and reference guides to ensure that all proper guidelines are followed for each payer source.
5. Once claim falls into your queue, correct any errors that are displayed.
6. Enters hospital charges into the system. Accesses the hospital system to ensure correct insurance is being billed.
7. Ensures that all hospital charge slips bear the proper CPT and ICD10 codes.
8. Monitors all system reports to ensure timely filing requirements.
9. Verifies correct PPS rate is received from Medicare and Medi-Cal. Verifies correct payment is received for all other insurance types. If payment received is same as the charge amount, notify Supervisor so charge can be adjusted if necessary.
10. Follows procedures as outlined by the Supervisor/Manager to ensure correct claims processing for each payer source.
11. Meets productivity goals established by Supervisor/Manager.
12. Resolves complex billing issues. Informs Supervisor/Manager of any system problems or payer problems that prevent you from collecting the amount due for claims.
13. Prints all necessary billing forms.
14. Updates CPT codes and ICD10 codes on claims as appropriate.
15. Posts all insurance payments. This will include manually inputting checks as well as processing electronic payments.
16. Monitors private pay accounts. Follows established procedures. After final attempt to collect, adjust as bad debt.
17. Posts all private pay payments received via the mail or from walk in patients.
18. Follows up on Explanation of Benefits (EOBs) and Remittance Advice (RADs) from insurance companies where either no payment or only partial payment is received.
19. Works insurance changes to financial classes sent to you by clinic staff. Updates and bills all accounts as necessary.
20. Opens mail, distribute as appropriate, prepares log sheet of checks and prepares daily deposit.
21. Assists Patient Accounts Manager and Supervisor with new procedures for special programs
22. Answers patient informational requests (both in person and on the telephone).
23. Collection activity to include write up of adjustment form.
24. Establishes payment plans with patients
25. Other duties as assigned by supervisor

QUALITIES &CHARACTERISTICS

1. Maintains a professional relationship and positive attitude with co-workers, the public, patients and all Ampla Health
2. Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through his/her actions
3. Strives to learn more and is receptive to learning different ways of doing things
4. Displays enthusiasm toward the work and the missions of Ampla Health

PROFESSIONAL KNOWLEDGE, SKILLS & ABLITIES

1. Must have high school diploma or equivalent
2. Ability to use Microsoft Word for basic correspondence
3. Ability to type a minimum of 40 WPM
4. Minimum of two years prior insurance billing experience, with knowledge of CPT Codes and ICD 10 Codes
5. Knowledge of hospital and dental billing
6. Knowledge of primary health care concepts
7. Ability to adapt to specific environment and duties

COMMUNICATIONS SKILLS

1. Must have neat and legible handwriting
2. Must be able to interact with patients courteously and calmly
3. Ability to communicate well with the public