PFS Representative I

SUMMARY :

Ensures the efficient handling of all insurance billing, follow up and collection activities. Communicates with insurance companies and state agencies.  Possesses strong knowledge of payer contracts and demonstrates complete understanding of payer billing requirements to ensure timely and accurate payment.  Completes reconciliation and billing of accounts making independent decisions based on payer, coding and billing guidelines.

ESSENTIAL FUNCTIONS :

Exhibits excellence in customer service through appropriate attitude and interaction with all customers, insurance plans, patients, visitors and staff.

Maintains and fosters effective public relations with patients and public.

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.

Assists management in maintaining or reducing account receivable (AR) days to meet industry standards and improve organizational cash flows.

Ensures patient accounts are billed and followed up on timely in a complete and accurate manner in accordance with payer contracts or guidelines.

Provides information regarding patient accounts in response to inquiries, safeguarding confidential information in verbal replies and correspondence.

Prepares and enters contractual write offs as identified.

Serves as information resource to patients and hospital staff regarding insurance claims.

Provides routine internal and external interface with internal and external department  staff and insurance payers, in order to resolve insurance related accounts.

Assists with problem solving, inquiries, and customer interaction to ensure positive results.

Analyzes patient accounts, reviews explanation of benefit and payer remits. Analyzes and processes contractual write offs as needed

Trains and assists in the implementation of new software programs / systems, system upgrades and related technologies.

Responds to insurance inquiries / requests as received either by mail or electronically.

Ensures all billing edits are completed daily for claim submission.

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION : High School diploma or General Education Degree (GED); or an equivalent combination of relevant education and experience.

EXPERIENCE : Three (3) years of related experience such as medical billing, medical insurance follow up in a physician or hospital setting.

LICENSURE OR CERTIFICATION : None required.

KNOWLEDGE, SKILLS AND ABILITIES :

• Knowledge of medical insurance practices and policies and regulations.
• Knowledge of fields on UB / 1500 claim forms.
• Knowledge of government and non-government uniform billing guidelines.
• Knowledge of medical terminology and coding Related to hospital billing and / or professional billing such as revenue, CPT diagnosis codes and modifiers.
• Skill in evaluating bills / claims for payers or patients in order to collect payment in a timely manner.
• Knowledge of resolving payer claim edits and rejections.
• Possesses and maintains knowledge of current regulatory and third party payer requirements to support billing reimbursement.
• Skill in providing assistance or training to other staff members in a team environment.
• Skill in the use of computer applications and systems including :   Excel, Word, Internet, email, and miscellaneous programs and networked computer systems.
• Ability to read and comprehend instructions, short correspondence, and memos.
• Ability to write correspondence; ability to effectively present information in one-on-one and small groups situations to customers, clients, and other employees of the organization.
• Ability to read and interpret documents such as safety rules, procedure manuals, and governmental regulations.
• Ability to meet productivity and quality review standards.
• Good organizational skills, adaptable to changes and ability to prioritize workload.
• Ability to function well under stress and handle high volumes of work.
• Ability to effectively present information and respond to inquiries or complaints from payors, patients and / or their representatives.
• Ability to calculate figures and compute reimbursement rates, and interpret bar graphs.
• Ability to apply common senses understanding to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.