Payment Resolution Analyst
Company: Saint Alphonsus
IN308_69603 Uro - Papfs West Usa Admin
Expected Weekly Hours:
The Payment Resolution Analyst serves as a specialist in ensuring that Trinity Health receives appropriate payment for delivered services. The position is expected to review, research and resolve payment delays and variances (over-payments and underpayments) incurred within the UEM, and processes payments in accordance with contracts and policies to ensure that all potential liabilities are paid in a timely and accurate fashion. This may include adjudicating claims, as appropriate; conducting formal account reviews; and analyzing and documenting delays and payment variances. Determine root causes for discrepancies and will interact with internal and external resources in recommendations for resolution that will minimize inappropriate payment delays and variances from expected reimbursement.
Job Description Details:
Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
Investigates and addresses: over-payment and underpayment accounts with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring that the claim is paid / settled in the most timely manner possible.
Coordinates Clinical account follow-up activities with Ministry Organization (MO) Utilization Review/Case Management to provide required support, as well as to ensure timely follow-up and action;
Applies knowledge of specific payer payment rules, managed care contracts, reimbursement schedules, eligible provider information and other available data and resources in order to r esearch payment delays and variances, make corrections, and take appropriate corrective actions to ensure timely claim resolutions;
Proactively follows-up on payment delays and variances by contacting patients and 3rd party payers, and supplying additional data, as required;
Composes adjustment and appeal letters, as needed to resolve underpayments;
Updates and refiles claims in a timely, accurate manner, and requests refunds, adjustments, write-offs, contractual/small balance/uncollectible allowances, bad debt transfers and/or balance reversals, if charges were improperly billed or if payments were incorrect;
Makes decisions regarding complexity of claim resolution and the appropriateness of transferring account to Collection vendor(s) or other resources for follow-up; and
Documents all actions and encounters in the patient accounting system using standard codes.
Responds to patient and 3rd party payer inquiries (telephone, fax, mail and web-based patient portal), complaints or issues regarding patient billing and collections, either responding directly or referring the problem to an appropriate resource for resolution.
Communicates with physicians and their office staff, Patient Access, Patient Accounting, Medical Records/Health Information Management, Utilization Review/Case Management, Managed Care, Ancillary and Nursing staff, as required to research and resolve discrepancies (e.g., request copies of medical records; obtain demographic, clinical, financial and insurance information; and create appeal letters).
May prepare special reports as directed by the Team Lead or Manager 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.).
May serve as relief support, if the work schedule or work schedule demands assistance to departmental personnel. May also be chosen to serve as a resource to train new employees. Cross- training in various functions is expected to assist in the smooth delivery of departmental services.
Other duties as needed and assigned by the Team Lead or Manager.
Maintains a working knowledge of applicable Federal, State, and local laws and regulations of multiple states, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
High school diploma or GED required. Associate degree in accounting or business administration highly desired. Data entry skills (50-60 keystrokes per minutes). Past work experience of at least two to five years within a hospital or clinic environment, an insurance company, managed care organization or other financial service setting, performing medical claims processing, financial counseling, financial clearance and/or customer service activities is required. In depth knowledge of insurance and governmental programs, regulations and billing processes (e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc.), managed care contracts and coordination of benefits is required. Working knowledge of medical terminology and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable. Basic computer skills are required.
Excellent communication (verbal and writing) and organizational abilities. Interpersonal skills are necessary in dealing with internal and external customers. Accuracy, attentiveness to detail and time management skills are required.
To successfully accomplish the essential job functions of this position, the incumbent will be required to work independently, read, write, and operate keyboard and telephone effectively.
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
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. Excellent problem solving skills are essential.
This position requires the ability to comprehend and retain information that can be applied to work procedures to achieve appropriate service delivery.
The greatest challenge in this position is to ensure that claim resolutions are performed promptly and in an accurate manner to assist in order to reduce potential financial loss to the patient and the Ministry Organization. The incumbent must have a thorough knowledge of various insurance documentation requirements, the patient accounting system, and various data entry codes to ensure proper service documentation and billing of the patient's account.
Position operates in an office environment. Work area is well-lit, temperature controlled and free from hazards. The incumbent is subject to eyestrain due to the many hours spent looking at a CRT screen. The noise level is low to moderate.
Must complete regulatory/mandatory certifications and skills validation competencies preferred.
Must possess the ability to comply with Trinity Health policies and procedures.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 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.
Trinity Health's 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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