To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Retrospectively reviews payment of claims on remittances to insure maximum reimbursement of accounts. Takes all necessary actions to expedite the prompt payment and/or resolution of capitated and managed care contracted accounts. Accurately analyzes and resolves credit balances via refunds, take backs or adjustments. Identify issues created by Managed Care contracts, complex billing regulations and other specific payment requirements. Serves as primary feedback mechanism to determine If contract specifications are being adhered to.
- 1. Retrospectively analyzes accounts and third party remittance in assigned work file to make sure we get paid correctly.
- 1.1 Using knowledge of capitated and managed care contracts verifies that payment amount expected is correct (i.e per diem, DRG payment, percentage payment programs, case rate payments and various UB92 Revenue codes as well as fee for service payments).
- 2. Use established follow up procedures to effectively expedite the prompt payment of claims.
- 2.1 Utilize the computer system to access daily work file to identify accounts requiring follow up activity.
- 3. Performs a variety of duties necessary to resolve individual inpatient and outpatient credit balances to ensure that all transactions on each account is correct.
- 3.1 Analyzes accounts utilizing a knowledge of the various billing requirements, contracts, regulations and coordination of benefit rules, and exercises sound judgement to come to a resolution of individual credit balance.
- 4. Analyzes correspondence and problems as they pertain to accounts and takes corrective action to ensure proper maintenance of account and facilitate payment.
- 4.1 Reviews and responds to internal and external mail/data/electronic mail within five (5) working days of receipt and returns telephone calls within 24 hours or the next business day.
- 5. Handles a high volume of third party accounts ensuring that accounts submitted to payors reflect accurate information. Submits claims through appropriate intermediary and works to insure that claims are processed and paid correctly.
- 5.1 Initiates actions necessary to correct problem or contacts individuals responsible for taking corrective action and documents in the system.
- 6. Keeps abreast of changing federal, state, and insurance regulations and the guidelines to capitated and managed care contracts in a dynamic healthcare environment.
- 6.1 Review all memos and policy updates regarding per diem rates, DRG payments, percentage payments, case rate payments and various UB92 revenue codes and any combination of these plans as well as the fee for service payment contracts, to ensure current follow up procedures.
- 7. Performs all other duties as requested by the supervisor to maintain a smooth operation of the department and contributes to group goals. The employee must also project a positive image of the department and the hospital.
- 7.1 Utilizes Excel (or equivalent software) to produce monthly Accounts Receivable Reports.
High school graduate with business related courses. Associate's degree in a business related field preferred, or equivalent work experience.
Three (3) to five (5) years billing or claims management experience in a hospital/healthcare computerized accounts receivable environment. Experience should include use of PCs.
Extensive knowledge of third party insurance carriers (Blue Cross, Medicare, Medicaid, Managed Care and capitated contracts) and their billing and reimbursement requirements. Excellent analytical and mathematical skills with a high degree of accuracy. Ability to perform detailed analysis quickly and accurately. Need to have keyboard skills of at lease 45 wpm and use a calculator. Ability to communicate effectively both written and verbally. PC skills including word processing, Excel, Microsoft Office, and other related software.