Previous Job
Collections Representative, Sr
Ref No.: 18-02621
Location: Emeryville, California
Start Date / End Date: 03/26/2018 to 07/30/2018
A Sr. Collections Representative falls into three categories:
1) Follow-up Collector, Refund Control Coordinator
2) Biller/Collector, Credit Specialist and Denial Specialist
3) High Dollar Commercial F/U Collector and Unit Lead Representative.
The duties of each category fall within the duties and essential job functions listed below.
A Sr. 1 Follow-up Collector is responsible for collections, conducting proactive follow up with payers and patients regarding non-payments, underpayments, or incorrect payments in a stratified manner. A F/U Collector calculates expected reimbursement, recommends accounts for collection agencies or legal assignment. A F/U collector negotiates prompt payment discounts and sets up payment plans according to departmental guidelines. A F/U Collector reconciles the accounts to closure. A F/U collector is knowledgeable of the medical center’s discount and charity policy.
A Sr. 1 Refund Control coordinator processes all types of refund requests initiated by PFS staff and management. Provides quality control review and ensures documentation is sufficient and accurate to support refund request according the Medical Center Audit guidelines. Processes return [non cashed] refund checks and records return checks in the accounting system. Performs uploads and downloads of processed refund requests to Accounting system to generate refund checks. Also processes debit and credit transactions in Accounting system [Peoplesoft] to transfer monies to Medical Center accounting system. [SMS]. Frequent contact with external departments regarding payment and refund transactions. Maintains archival of paper refund requests and backup of all electronic uploads and downloads to the Medical Center accounting system.
A Sr 2 Biller/Collector is responsible for both billing and collections, gathering and securing all information needed for billing, follow up, and payment of accounts in accordance with the specific payer guidelines, policies, procedures, and compliance regulations. This includes maintaining the deficiency (QUIC) lists used to obtain missing documents from internal or external entities, resolving claim rejections, packaging claims, including global billing with attachments of professional fee claims, performing proactive follow up with payers, grants and other entities and securing payment of accounts. The biller/collector is accountable and responsible for billing through account closure.
A Sr. 2 Credit Specialist is responsible for resolving accounts with credit balances. These include credits associated with audit findings and overpayments/overadjustments by payors and patients. Additionally, a Credit Specialist reviews requests for refunds from payors and coordinates the rebilling process to the primary payor following departmental guidelines. A Credit Specialist is also responsible for collections of accounts refunded by the Medical Center and payment retractions generated by the payor. A Credit Specialist reviews external auditor refund requests for management approval. A Credit Specialist is responsible for resolving credits by meeting payor quarterly/annual balance report requirements and cancelling or adjusting previous claims submissions.
A Sr. 2 Denial Specialist is responsible for review of payor denials related with ‘off label/experimental’ usage of drugs, supplies and services. The Denial Specialist works closely with medical center departments to determine whether the denial qualifies for drug replacement by the manufacturer. The Denial Specialist reviews patient payment arrangements set at time of registration and adjusts accounts following department guidelines. 90% The Denial Specialist is responsible for the monthly maintenance and distribution of the hospital department denial reports. 10%.
A Sr. 3 High Dollar Commercial F/U Collector is responsible for collections and resolution of our highest commercial balances and worklists. High Dollar collectors conduct proactive follow up with payors regarding nonpayment, underpayments or incorrect payments in a stratified manner. High Dollar collectors negotiate prompt payment/in lieu of audit discounts as delineated in the departmental guidelines. High Dollar Collectors reconcile the accounts to closure.
A Sr. 3 Lead Representative is an experienced staff with lead responsibilities. Job functions may parallel duties and responsibilities of AAII, AAIII, Sr 1 and Sr2 but job duties require advance knowledge to serve as a resource person to other staff members and management. A Lead Representative is responsible in assisting with training and monitoring backlogs. Leads are assigned special projects.
Senior Collections Representatives utilize multiple databases and applications to analyze and take appropriate action on information or documents received. Applications and Databases consist of: SMS, Hospital Rates, TSI, IDX, IMF, CIRIUS, CPT88888, DClientata, Encoder, Procodes, Authorization, Imaging, Implant, STOR, Canopy, EMRWeb, CCS, Advanced Beneficiary Notice, UCare, Transplant, OUTSIDE LABS, and various payer websites.
Frequent contact with Patient Financial Services staff, clinic management, and managers, as well as, patients, billing and professional fee and collection services vendors.
1. Secure all forms and pertinent information for billing (i.e., medical records reports, DOFRs, EOBs, R/A’s, COB information, departmental reports, authorizations, precertifications, TARs, MSP forms, UPIN/PIN #’s, physician license #’s, consents, and other information as required). Biller/Collector, Lead
2. Review all bills and accounts for accuracy, completeness, and compliance with all local, state, and federal requirements (i.e., diagnosis codes, procedure codes, UB codes, UB92 claim completion, charges, billing information, etc.). Biller/Collector, Credit Specialist, Denial Specialist, Lead
3. Sort hardcopy bills stratified by dollar amount. Biller/Collector, Lead
4. Submit bills to payers in a timely and stratified manner in accordance with department and payer requirements. All
5. Enter detailed on-line notes as to where, when and dollar amount billed providing an audit trail for future follow up. All
6. Complete billing WIP, activity reports and batch QUIC logs as required. Biller/Collector, Lead
7. Work error reports and transmit corrections on electronically submitted claims as required. Biller/Collector, Lead
8. Bill secondary insurance as required. Biller/Collector, Lead
9. Check on-line contract information as required. All
10. File appeals and contact the managed care department as required. All
11. Secure guarantor/patient demographic and/or insurance information as required. Update the on-line system with accurate and complete information. All
12. Inform appropriate parties according to established guidelines of CPT4/HCPCS coding problems, incorrect UB codes, incorrect insurance plan codes, addresses, and compliance issues as required. All
13. Check on-line systems for eligibility and/or benefit verification (i.e. DDE, CERTS, POS, Share of Cost, etc.) including claim status from payer websites. All
14. Maintains a thorough working knowledge of billing procedures per established office policies, county, state and federal regulations. All
15. Enter accounts with deficiencies on the appropriate QUIC lists for accountability and management. Maintains current status by updating, deleting, adding and tracing aged accounts with responsible entities. Biller/Collector, Lead
16. Conducts proactive follow up with payers regarding non-payments, underpayments, or incorrect payments in a stratified and timely manner. Files appeals meeting payer format and timely appeal requirements. All
17. Processes all payer denials, inquiries and correspondence in a timely and stratified manner. F/U collector, High Dollar Collector, Denial Specialist, Lead
18. Monitors current status of billing and collections in a stratified manner via STAT lists by directing appropriate questions to responsible departments or agencies. All
19. Add/update insurance information, payer information and financial class information as needed. All
20. Prepare accounts for transfer to collection agencies, attorneys and other agencies as per established department/hospital guidelines. All
21. Maintains current status of accounts by processing late charges, credits, corrected billings, write offs, refunds, contractual adjustments or charity determinations as required. All
22. Receives and resolves to completion, incoming calls from patients, insurance companies, M-Cal Field Office, CCS, other third party payers, hospital departments, and external entities as required. All
23. Calculate expected reimbursement. All
24. Analyze accounts for discounts or charity adjustment in accordance with established policies. All
25. Ensure reimbursement is accurate and appropriate contractual allowances have been applied.
26. Elevate problem accounts to a supervisor in a timely manner. All
27. Medicare Specific Requirements
A) Calculate patient covered days to determine coinsurance and lifetime days per spell of illness.
B) Monitor claims for 72-hour overlaps.
C) Split bills to encompass covered versus non-covered days, rehab days, and Part B only charges, etc.
D) Review all accounts to verify primary coverage (i.e. MSP issues, Medicare HMOs, Part B only etc).
E) Process incoming R/A’s to determine secondary billing.
F) Understand and Operate the DDE/QUBE systems as required.
G) Process all M-Care denials, mail-backs and adjustments electronically.
H) Check accounts for accuracy according to Medicare HMO guidelines.
I) Knowledge on ADR requirements and processing.
28. Medi-Cal Specific Requirements
A) Contact Field Office or CCS as required.
B) Review all accounts to verify primary coverage (i.e., fee-for- service M-Cal, M-Cal HMO, CCS, etc.)
C) Review for SOC and processes accounts per established departmental guidelines.
D) Monitor claims for overlaps.
E) Work denial/suspended accounts.
F) Operate the M-Cal electronic billing system as required.
G) Obtain eligibility using POS, CERTS, or other systems a required.
H) Ensure appropriate M-Cal specific billing codes are used where applicable.
I) Complete daily billing report.
J) Must have a through understanding of RTDs, CIFs, denials, suspends and other M/Cal specific rules and regulations.
K) Knowledge of TAR requirements.
L) Knowledge of billing attachment requirements.
M) Knowledge of billing requirements for the various M-Cal programs.
N) Knowledge of M-Cal covered and non-covered services.
29. Commercial, Contracts, and Managed Care Specific Requirements
A) Analyze and interpret the various managed care contracts to ensure compliance with the terms and conditions of the contract.
B) Ensure appropriate Worker’s Compensation specific billing codes are used where applicable.
C) Ensure appropriate authorizations, pre-certifications are on file and appropriately documented on the UB92 and/or on-line systems as required.
D) Thorough understanding of all UB92 field requirements.
E) Ensure correct payer codes and billing addresses are used in accordance with Client’s managed care contracts, Worker’s Compensation carrier, indemnity insurance company, or other third party.
30. Commercial Managed Care Transplant Billing and Collections
A) To administer all non-governmental commercial insurance contracts according to specific contract guidelines, which can include the global billing of professional fee claims and outside services provided to transplant patients.
B) Ensure appropriate procedures are following and account data is updated and reported at all times in the PFS Transplant Database Application to ensure accurate reporting of all transplant data.
C) Processing of package billing in accordance with contract requirements and ensuring that all payments are reviewed and analyzed to facilitate payment to professional fee billing groups.
D) Thorough and complete use of TRAC worklist and activity codes to ensure accounts are appropriated and identified by current status in A/R.
E) Analyze and prepare adjustments to A/R when appropriate and applicable to claim follow up at all stages of billing (i.e. interim and final billing for post payment review).
All the above processes and procedures must be completed in accordance with the HIPAA mandated rules, regulations and requirements and in accordance with Client Medical Center and PFS Department policies.