Payment Resolution Specialist - FT - Days - Billing and Collection @ MV
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 (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 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.
- Evaluates 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Hospitals
Education Level
High school or GED
Number of Employees
1,001-5,000 employees
