The Commercial Follow Up Specialist is responsible for supporting management by performing resolution-oriented follow-up to achieve positive cash flow and accounts receivable goals of hospital assigned inpatient and outpatient patient accounts and reconciliation of account issues. Specialists are responsible for working with multiple payors in issue resolution, resolving problem accounts, managing correspondences with payers, and working continuously to improve aging of receivables while minimizing controllable losses.
1. Maintains the best practice routine per department guidelines working relevant work queues daily, documenting issues and follow-up with payers or applicable departments in a timely manner per process with required documentation noted in system.
2. Screens claims on-line or on paper for accuracy and obtain additional information for processing.
3. Plans daily workload effectively for maximum process and financial impact
4. Works in an independent and self-motivated manner to maximize daily efficiency
5. Navigates multiple software applications (RelayHealth ePremis, AllScripts, etc.) on a daily basis
6. Completes timely follow-up on assigned patient accounts, in a compliant manner
7. Identifies trends and their root causes within assigned inventory
8. Maintains an appropriate level of productivity as defined by DeKalb Medical Center’s follow-up performance metrics
9. Updates manager or supervisor of issues impacting follow-up efficiency and effectiveness, as necessary
10. Analyze and process correspondence including rejections, requests for medical records, itemized bills, clarification of detail on bill, etc.
11. Analyze paid claims for accuracy of payments and or rejections and properly account for payment and adjustments.
12. Monitors patient accounts for timely follow-up and prompt resolution of denials or other basic account resolution.
13. Reconciles accounts receivable records with pending claim inventories for Commercial payors.
14. Verifies insurance benefits to maximize reimbursement.
15. Communicates daily via the telephone or written communication with payors, patients, and departments to obtain and provide all information for payers to process and pay claims quickly and accurately.
16. Works with other departments (e.g. PFS, HIM, Case Management, etc) to appropriately contribute to account resolution and manage receivables.
17. Gathers data, summarizes and prepares reports for management and completes special projects as assigned.
19. Attends periodic meetings with payer representatives to discuss discrepancies and assist in developing action plan for correction.
21. Participates in continuous quality improvement activities and teams
22. Participates in supporting the organization’s vision, mission and values and adheres to DeKalb Medical Standards of Behavior
23. Performs other duties as assigned or requested
Minimum Education, Experience and Licensure Required:
· High School Diploma, GED or equivalent combination of experience and education
· At least 5 years in an office clerical setting, with at least 2 year of experience in a hospital, payor or clinic business office setting.
· Experience with automated patient accounting system and Revenue Cycle processes
· Experience with general accounting required
· Associate’s Degree program in Accounting, Business Administration or a related area of study preferred
Skills, Knowledge and Abilities:
· Requires working knowledge of accounting, healthcare and general office procedures.
· Requires working knowledge of accounting principles that directly impact the accounts receivable, including debit and credit transactions; charge transfers; contractual allowances and adjustments; financial class changes.
· Requires working knowledge of the reimbursement and regulatory environment so as to ensure compliance regarding patient and insurance billing issues.
· Requires working knowledge of insurance regulations, managed care practices, regulatory agencies and alternative funding sources.
· May require assistance in completing appropriate follow through for complex accounts.
· Requires working knowledge of standard PC word processing, spreadsheet applications, and website navigation for payor follow up
· Requires excellent communication skills to clearly and concisely communicate verbally and in writing with peers, supervisors, payers, physicians, patients, other departments, etc.
· Ability to understand and enforce system credit, bad debt and charity policies and use of other financial assistance resources (e.g. bank loans, payment plans, etc).
· Requires strong problem solving skills to address payer and patient issues appropriately and know when to ask for assistance.
· Requires knowledge of different cultural group’s needs and desires, as well as customer service knowledge and skills.
· Requires moderate process improvement skills.
· Requires knowledge of confidentiality policy.
· Requires conflict management skills and time management skills.
· Proficiency in Microsoft Office products (e.g. Word, PowerPoint, and Excel) and website navigation for healthcare billing
· Demonstrates understanding of medical terminology
· Knowledge of CPT, HCPCS, ICD-10 coding procedures
· Working knowledge of Commercial, Commercial and Managed Care insurance carriers
· Performs skills and competencies as defined in orientation checklist and annual departmental competency checklist if applicable.
· Demonstrates and maintains competencies specific to patient population served.
Reports to: Commercial Supervisor