Payment Resolution Specialist - FT - Days - Facilities Srvc-Projects @ MV

El Camino Health • Mountain View, CA

3d • Onsite

About The Position

The Payment Resolution Specialist performs managed care insurance payment audit/underpayment identification, research, analysis, reporting, and collections functions. Ensures claims are paid appropriately pursuant to negotiated payment rates in El Camino Hospital’s contractual agreements with managed care insurance payers. Reports all significant underpayment issues, trends, and systemic issues to Revenue Cycle Senior Management to ensure there is no adverse effect on Hospital Cash Collections or Accounts Receivable. Keeps informed of managed care and contractual arrangements in order to resolve and process accounts by managed care insurance payers. Follows up on all payment variances for account resolution through insurance payer’s online tools, phone calls, and periodic in-person meetings with insurance payer liaisons. Collaborates closely with the Contracting Services Department to facilitate escalation of significant and systemic insurance payment issues. Ensure all accounts are resolved in a compliant manner and according to all applicable hospital policies/procedures, rules, and regulations. After multiple unsuccessful appeal attempts, the Payment Resolution Specialist is tasked with carefully evaluating all factors and exercising prudent decision making to determine whether to continue or cease pursuit of insurance payment, subject to specific dollar threshold(s) outlined in hospital policies and procedures.

Requirements

• High School Diploma or equivalent
• Minimum of five (5) years related work experience in a Hospital Billing setting
• Minimum of three (3) years related work experience involving interpretation/analysis of managed care contract payment terms
• Strong critical thinking and analytical skills
• Strong verbal and written communication skills
• Proficient in HMO, PPO, Managed Medicare, Managed Medi-Cal, and 3rd party rules and regulations
• Proficient in managed care contracting payment terms and rate structures for hospitals
• Works in a collaborative and team manner
• Basic to intermediate skill level in Microsoft Excel

Nice To Haves

• Microsoft Access is a plus

Responsibilities

• Performs managed care insurance payment audit/underpayment identification, research, analysis, reporting, and collections functions.
• Ensures claims are paid appropriately pursuant to negotiated payment rates in El Camino Hospital’s contractual agreements with managed care insurance payers.
• Reports all significant underpayment issues, trends, and systemic issues to Revenue Cycle Senior Management.
• Keeps informed of managed care and contractual arrangements in order to resolve and process accounts by managed care insurance payers.
• Follows up on all payment variances for account resolution through insurance payer’s online tools, phone calls, and periodic in-person meetings with insurance payer liaisons.
• Collaborates closely with the Contracting Services Department to facilitate escalation of significant and systemic insurance payment issues.
• Ensures all accounts are resolved in a compliant manner and according to all applicable hospital policies/procedures, rules, and regulations.
• Evaluates all factors and exercises prudent decision making to determine whether to continue or cease pursuit of insurance payment, subject to specific dollar threshold(s) outlined in hospital policies and procedures, after multiple unsuccessful appeal attempts.

Benefits

• El Camino Health will provide reasonable accommodations to qualified individuals with a disability if that will allow them to perform the essential functions of a job unless doing so creates an undue hardship for the hospital, or causes a direct threat to these individuals or others in the workplace which cannot be eliminated by reasonable accommodation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED