Payment Variance Representative, FT, Days,

Prisma Health•Columbia, SC

About The Position

Inspire health. Serve with compassion. Be the difference. Job Summary Ensures claims are paid appropriately pursuant to negotiated payment rates in Hospital’s contractual agreements with all insurance payors. Evaluates and submits payment discrepancy disputes when appropriate. Essential Functions Abides by all applicable policies, procedures, and guidelines of the Prisma Health System. Maintains knowledge of payor contract guidelines and resolves inconsistencies in payor compliance with contract terms, conditions, and rates. Analyzes payor payments and collaborates with other departments to process appeals and resolve appropriate underpayments. This includes application of appropriate contract terms, fee schedules, identification of trends, and reporting trends to management. Research insurance credit balances/adjustments to ensure accuracy of transactions and appropriate disbursement of funds due to insurance payors. Ensures timely follow-up and appropriate action for assigned accounts. Review payor refund requests to resolve reimbursement discrepancies. Initiates appeals or adjustments based on contract interpretation, payor policies and procedures. Meets productivity and quality standards according to departmental policy. Troubleshoots claim pricing in Prisma Health’s Information Systems and offers suggestions for improvement. Makes recommendations regarding complexity of claim resolution and the appropriateness of transferring account to collection vendor(s) or other resources for follow-up. Works closely with team members and management to participate and provide comprehensive training regarding appeals processing, process improvement, payor contracting and revenue cycle issues that impact reimbursement. Must adhere to all Prisma Health System Service Values. Performs other duties as assigned.

Requirements

Education - High School diploma or equivalent or post-high school diploma / highest degree earned
Experience - 5 years - B ookkeeping, invoice/account reconciliation or healthcare revenue cycle/medical office experience required . (Managed care, payor contracting & reimbursement, denials and/or appeals experience preferred.)
In Lieu Of Bachelor’s degree would substitute for three of the five years of required experience.
Superior written and oral communication skills.
Excellent Microsoft Office Skills, including the use of pivot tables and other functions in Excel.
Strong critical thinking and analytical skills.
Ability to work autonomously.
Working knowledge of CPT and DRG coding practices.
Ability to evaluate and prioritize workload.
Ability to quickly problem solve and identify appropriate issues for escalation to management.
Working knowledge of billing requirements for Government and Commercial Payors.

Nice To Haves

Certified Specialist Payment & Reimbursement (CSPR), Certified Revenue Cycle Representative (CRCR) or Certified Revenue Cycle Representative (CRCR) - Preferred

Responsibilities

Ensures claims are paid appropriately pursuant to negotiated payment rates in Hospital’s contractual agreements with all insurance payors.
Evaluates and submits payment discrepancy disputes when appropriate.
Abides by all applicable policies, procedures, and guidelines of the Prisma Health System.
Maintains knowledge of payor contract guidelines and resolves inconsistencies in payor compliance with contract terms, conditions, and rates.
Analyzes payor payments and collaborates with other departments to process appeals and resolve appropriate underpayments.
Research insurance credit balances/adjustments to ensure accuracy of transactions and appropriate disbursement of funds due to insurance payors.
Ensures timely follow-up and appropriate action for assigned accounts.
Review payor refund requests to resolve reimbursement discrepancies.
Initiates appeals or adjustments based on contract interpretation, payor policies and procedures.
Meets productivity and quality standards according to departmental policy.
Troubleshoots claim pricing in Prisma Health’s Information Systems and offers suggestions for improvement.
Makes recommendations regarding complexity of claim resolution and the appropriateness of transferring account to collection vendor(s) or other resources for follow-up.
Works closely with team members and management to participate and provide comprehensive training regarding appeals processing, process improvement, payor contracting and revenue cycle issues that impact reimbursement.
Must adhere to all Prisma Health System Service Values.
Performs other duties as assigned.