Payment Resolution Specialist-II (Hospital Denials & Appeals) - PFS (Remote)
Trinity Health

Job Info

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Employment Type:
Full time
Shift:
Day Shift

Description:
Work Remote Position
(Pay Range: $20.1351-$30.1699)
POSITION PURPOSE

Performs day-to- day payment resolution activities within the Hospital and/or Medical Group revenue operations ($3-5B NPR) of an assigned Patient Business Services (PBS) location. The scope of responsibility will be all post-billed denials (inclusive of clinical denials). Serves as part of a team of payment resolution colleagues at an assigned PBS location responsible for determining root causes for discrepancies, minimizing inappropriate payment delays and variances from expected reimbursements, ensuring payments are received on denied accounts, and resolving or escalating issues to the Supervisor Payment Resolution Supervisor for resolution. Provides training and guidance to Payment Resolution colleagues and resolves problems as needed. This position reports directly to the Supervisor Payment Resolution.

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Reviews, researches and resolves payment delays and/or variances resulting from rejected and/or denied claims and/or overpayments and underpayments.

Processes payments as appropriate in accordance with contracts and policies to ensure that all potential liabilities are paid in a timely and accurate fashion.

Resolves claims, conducts formal account reviews, identifies lost charge recovery, and analyzes and documents delays and payment variances.

Identifies systemic issues and either resolves or escalates to Supervisor Payment Resolution for resolution.

Maintains knowledge of state/federal laws as they relate to contracts and the appeals process.

Assists in training Payment Resolution Specialist I colleagues upon hire and as new systems and processes are created.

Resolves problems on issues as needed.

Investigates and addresses overpayment and underpayment accounts with the objective of appropriately optimizing reimbursement for services rendered. Ensures that claims are paid/settled in the timeliest manner possible:

• Coordinates follow-up activities with Utilization Review/Case Management/Coding/Nurse Liaison to provide required clinical support, as well as to ensure timely follow-up and action for account appeals.
• Works with Patient Access and other necessary parties to resolve account authorization issues.
• Applies knowledge of specific payer payment rules, managed care contracts, reimbursement schedules, eligible provider information and other available data and resources in order to research payment delays and variances, make corrections, and take appropriate corrective action to ensure timely claim resolution.
• Proactively follows up on payment delays and variances by contacting patients and third-party payers, and supplying additional data, as required.
• Composes adjustment and appeal letters to resolve payment rejections and/or denials.
• Updates and refiles timely, accurate claims.
• Reports and maintains data on types of claims denied and root cause of denials. Collaborates with management and team to make recommendations for improvements.
• Requests write offs, transfers, allowances, and reversals.
• Makes decisions regarding complexity of claim resolution and the appropriateness of transferring account to collection vendor(s) or other resources for follow-up.
• Documents all actions and encounters in the patient accounting system using standard codes.
• Maintains working knowledge of payer contracts and payer payment rules.
• Actively participates in Joint Operating Committee meetings with payers on current issues.
  
  

Responds to patient and third-party payer inquiries, complaints or issues regarding patient billing and collections, or refers the problem to an appropriate resource for resolution.

Communicates with physicians and their office staff and appropriate hospital departments as required to research and resolve discrepancies, e.g., request copies of medical records, obtain demographic, clinical, financial, and insurance information.

Prepares, maintains, and submits special reports as directed by the Supervisor Payment Resolution to document billing, follow-up services and payment variance services, outcomes and trends, e.g., number and types of claims and dollars rejected/denied, billing errors, payer processing errors, potential versus actual recoveries, claims edited, number of claims unprocessed, etc.

Cross trains in various functions to assist in the streamlined delivery of department services.

Interprets data, draws conclusions, reviews findings and provides recommendations. Participates in special projects as directed by the Supervisor Payment Resolution.

Takes initiative to continuously learn within assigned job function to support progressive responsibility.

Other duties as needed and assigned by the supervisor.

Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior

MINIMUM QUALIFICATIONS

High school diploma or Associate degree in Accounting or Business Administration or related field, and a minimum of four (4) years' experience within a hospital or clinic environment, a health insurance company, managed care organization or other health care financial service setting, performing medical claims processing, financial counseling, financial clearance, accounting or customer service activities or an equivalent combination of education and experience. Experience in a complex, multi-site environment preferred. Excellent written and verbal communication skills and organizational abilities.

Strong interpersonal skills in interacting with internal and external customers.

Strong accuracy, attention to detail and time management skills.

Basic understanding of Microsoft Office, including Outlook, Word, PowerPoint, and Excel.

Completion of regulatory/mandatory certifications and skills validation competencies preferred.

Must be comfortable operating in a collaborative, shared leadership environment.

Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

This position operates in a typical office environment. The area is well lit, temperature controlled and free from hazards.

Incumbent communicates frequently, in person and over the phone, with people in all locations on product support issues.

Manual dexterity is needed in order to operate a keyboard. Hearing is needed for extensive telephone and in person communication.

The environment in which the incumbent will work requires the ability to concentrate, meet deadlines, work on several projects at the same time and adapt to interruptions.

Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.

Must possess the ability to comply with Trinity Health policies and procedures.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

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