Patient Financial Services Representative/Medicare

South Shore Health•Weymouth, MA

About The Position

Patient Financial Services Representatives ensure the financial aspects of patient healthcare are handled efficiently and professionally. The role prepares, submits, and follows up on compliant hospital and physician insurance claims using the Epic Billing System to support payment. It also involves contacting insurers to resolve claim denials and discrepancies. Medicare collection experience and knowledge are highly desired. The representative maintains knowledge of billing regulations and payer policies, works claim and accounts-receivable queues, resolves denials and payment issues, documents account activity, and coordinates with insurers, patients, clinical departments, patient access, and denial management staff. The position also reviews credit balances, supports workflow improvements and departmental projects, and uses Epic and other workplace technology. Hybrid or remote work options may be available after training.

Requirements

High school graduate or above preferred.
Two years of hospital and/or physician billing experience preferred.
Knowledge of healthcare billing, insurance plans, codes, and reimbursement methodologies.
Proficiency in data entry and basic computer skills, including Microsoft Office Suite.
Strong organizational and multitasking skills.
Strong interpersonal and communication skills.
Strong analytical and independent decision-making skills.

Nice To Haves

Medicare collections and knowledge.
High school graduation or above.
Two years of hospital and/or physician billing experience.

Responsibilities

Maintain current knowledge of federal, state, and insurance-specific billing regulations, policies, procedures, and code sets; notify the manager of changes affecting claim submission.
Protect patient privacy and confidentiality in accordance with HIPAA and comply with applicable payer and organizational billing requirements.
Monitor payer policy updates and communicate changes that may affect billing, collections, denials, or reimbursement.
Review daily claim files using Claim Edit and Charge Review work queues and prepare UB-04 and 1500 claim forms for submission.
Correct claims in accordance with payer regulations and hospital policy, work external clearinghouse edits, and resubmit claims through Epic.
Collect aged accounts receivable through Epic work queues, prioritizing accounts according to organizational goals and aging criteria.
Contact insurance companies by phone, email, or designated websites to resolve outstanding balances and incomplete accounts.
Collaborate with denial management staff when clinical intervention is needed for appeals, and work with clinical departments, patient access, and other departments to resolve account issues.
Generate technical appeals, provide detailed account histories for accounts considered uncollectable, and document actions in Epic account or follow-up/denial notes at least every 30 days for accounts requiring follow-up.
Escalate payer issues to the Provider Representative and participate in monthly meetings.
Meet defined quality and productivity measures; identify denial or payment trends and escalate them to management.
Handle payer 277 rejections and resubmit them through Epic; reconcile account balances and apply appropriate adjustments according to established policies.
Review credit work queues and credit balances, requesting refunds or payer retractions as needed.
Contact patients by phone or letter for additional insurance or other information needed to process claims before accounts are placed in self-pay status.
Verify predefined patient demographic information and maintain documentation to verify identity.
Use the MyTime payroll system, Epic, Microsoft Outlook, provider websites, SharePoint, and OneDrive as required.
Foster a culture of safety by completing annual safety education, maintaining an organized work environment, and following respiratory etiquette guidelines.
Assist with workflow improvements, special projects, audits, and process-improvement initiatives.
Perform other duties assigned by management in accordance with department needs.