PFS Revenue Cycle Representative - Pt Acctg-Billing/Collections (1.0 FTE, Days)

Revenue Cycle

1.0 FTE, 8 Hour Day Shift

At Stanford Children's Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

This paragraph summarizes the general nature, level and purpose of the job.

The is responsible for the timely and accurate processing of patient accounts receivable collections. The specific job duties will be comprised of a combination of responsibilities from among the various areas of PFS operations includingAccounts Receivable collections and payer follow-up, Payer denial review and appeals processing, Customer service, Payment applications, Credit balance review and resolution and Patient advocacy and risk management. The position is an expert-level position with a superior background in hospital patient accounting and an extensive knowledge of reimbursement requirements of healthcare payers. The will act as a key resource for the team management in problem solving difficult issues and analyzing difficult accounts.

Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the hospital's policies and procedures, including its Service Standards and its Code of Conduct.

• Review and correct all billable claims in billing software in accordance with payor specific guidelines and billing requirements within one working day.
• Work with HIM and applicable departments to resolve questions related to modifiers, orphan CPT/HCPCS codes, charge entry errors, ICD-9 and CPT/HCPCS coding errors, and other questionable claim form elements such as discharge disposition.
• Perform timely and appropriate follow-up to resolve unbillable claims. Using Interpoint, document in account notes all reasons for billing delays and actions taken. Apply the appropriate hold reason code in billing software.
• Process secondary billing in accordance with department procedures.
• Every time an account is accessed, review and correct all account discrepancies, update demographics and other field values such as mnemonic, insurance and billing information, etc., to ensure data integrity in Cerner/Meditech as well as in the billing software.
• Review all high dollar claims for potential stop-loss criteria and direct stop-loss claims to correct payor processing unit.
• Prepare and submit appropriate billing attachments as required by specific payors.
• Mail paper claims to appropriate payors.
• Review daily claim rejection reports, resolve rejection issues, and resubmit corrected claims to ACS within 24 hours of rejection.
• Collaborate with manager to resolve claim submission delays exceeding five working days.
• Inform manager of recurring claim errors in order to facilitate system improvements.
• Review and resolve non-covered charges according to facility procedures.
• Review late charge report. Submit late charge or adjustment claims, or write off late charges as appropriate per facility procedures.
• Review assigned Interpoint worklists to ensure appropriate and timely actions are completed.
• Review and respond to mail, correspondence and reports on a daily basis.
• Validate that all charges and/or accounts have been combined in accordance with regulations prior to claim submission.
• Request and submit interim claims on long-term care inpatients every 30 days.
• Perform timely and appropriate follow-up on unpaid, underpaid, suspended, and denied accounts.
• Review credit balance accounts and take appropriate action to resolve the credit balance.
• Review remittance advices to ensure payments are correct for services rendered and resolve payment discrepancies.
• Submit adjustment request to reduce account balance for "not medically necessary" (failed) services where an ABN was not obtained.
• Document payment details in patient account notes according to EOB documentation standards.
• Evaluate EOBs and remittance advices by comparing amount paid against the expected reimbursement amount.
• Evaluate denials to determine if appeals are warranted.
• Submit adjustment requests as necessary to ensure that contractual discount amounts are correct according to contract terms.
• Close carrier on correctly paid accounts when patient owes a share of cost (SOC), update financial class to next carrier and validate that account balance matches total patient responsibility amount as determined by Medi-Cal.
• Escalate unresolved or unreasonably delayed appeals to Manager for special handling and/or assessment.
• Utilize all available tools and resources to perform follow-up in the most efficient manner electronic transactions, Internet, phone calls, etc.
• Submit denial adjustments on denied amounts not likely to be paid on appeal, if not billable to a subsequent payor.
• Review and respond to mail, correspondence and reports on a daily basis.
• Review credit balance accounts and take appropriate action to resolve the credit balance.
• Understand and comply with all current Medi-Cal regulations.
• Work with departmental staff, hospital departments, physicians, physician's office staff, government agency and insurance company representatives, patients, consultants and co-workers.
• Maintain confidentiality of all patient information.
• Ensure all billing documentation required by payers, including but not limited to CPT-4, HCPCS and ICD-9 coding, prior authorization, provider identifications, primary and secondary insurance, patient demographics, insured identification, charges and dates of service are complete and correct.
• Complete claims submission on a daily basis.
• Follow-up on 50 accounts per day. Follow-up is defined as activity performed that creates account resolution.
• Percentage of accounts receivable > 60 days must remain below 36.0% of the total outstanding Medi-Cal balance on a monthly basis.
• Percentage of accounts receivable > 90 days must remain below 15.0% of the total outstanding Medi-Cal balance on a monthly basis.
• Percentage of accounts receivable > 120 days must remain below 10.0% of the total outstanding Medi-Cal balance on a monthly basis.
• Percentage of accounts receivable > 180 days must remain below 6.0% of the total outstanding Medi-Cal balance on a monthly basis

Minimum Qualifications

Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Education: High School diploma or GED equivalent

Experience: Two (2) years of progressively responsible and directly related work experience in a healthcare setting

License/Certification: None

Knowledge, Skills, & Abilities

These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.

• Ability to follow oral and written instructions and interpret institutional and other policies accurately.
• Knowledge and appropriate use of electronic claims billing system.
• Ability to gather, analyze, and display data in appropriate format and keep accurate records.
• Ability to maintain confidentiality of sensitive information.
• Ability to perform basic mathematics.
• Ability to plan, prioritize and meet deadlines.
• Ability to work effectively with individuals at all levels of the organization.
• Knowledge insurance and medical terminology.
• Knowledge of accounts receivable system like SMS, IDX, or Meditech.
• Knowledge of computer systems and software used in functional area.
• Knowledge of medical reimbursement policies and procedures.
• Knowledge of one or more of the following: Medicare, Medi-Cal, Worker's Comp or Managed Care (HMO,PPO,POS, etc).
• Knowledge of principles and practices of customer service and telephone courtesy.

Physical Requirements and Working Conditions

The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.

Pay Range

Compensation is based on the level and requirements of the role.

Salary within our ranges may also be determined by your education, experience, knowledge, skills, location, and abilities, as required by the role, as well as internal equity and alignment with market data.

Typically, new team members join at the minimum to mid salary range.

Minimum to Midpoint Range (1.0 FTE): $74,318.40 to $84,312.80

Equal Opportunity Employer

L ucile Packard Children's Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.