PFS Specialty Group Representative 1

Mercyhealth Wisconsin and Illinois•Remote-Wisconsin, WI

8d•Onsite

About The Position

This role involves researching and performing audits on patient accounts to ensure correct billing to payers. The representative will need a thorough understanding of billing accuracy, available resources like medical records and chart view, and collection laws for worker's compensation and third-party liability claims. Proficiency in the Single Billing Office environment within Epic and knowledge of common billing and account resolution practices for hospitals and clinics are essential. The position requires learning and mastering various applications used by Patient Financial Services, identifying the correct insurance filing order, and responding to inquiries from patients, insurance companies, and other vendors. Responsibilities also include processing refunds for credit balances, responding to billing reviews from other PFS groups, documenting all account interactions, and protecting patient confidentiality. The representative will review settlement requests, work on special projects, verify claim receipt and follow-up, resolve denied claims, obtain and send medical records, and draft appeal letters. They will also call patients, payers, and attorney offices to gather information, identify denial trends, and collaborate with revenue cycle staff. The role includes working assigned work queues, reports, and spreadsheets, and participating in department meetings and training. Adaptability to change and maintaining productivity standards are key. Mercyhealth is an integrated health system serving northern Illinois and southern Wisconsin, recognized for its commitment to its people and culture.

Requirements

High school diploma or equivalent
Microsoft Excel required
Basic understanding of working in multiple software applications at the same time.
Proven ability to work effectively in a team environment.
Strong typing/data entry experience.
Strong organizational skills and attention to detail, accuracy and follow-through.

Nice To Haves

Healthcare billing experience preferred.
Undertakes self-development activities.
2 - 3 years customer service experience preferred or 1 year customer service in medical field preferred.
Knowledge of medical terminology preferred.

Responsibilities

Research and perform audits on patient accounts to determine balances are being billed to the correct payer.
Thoroughly understand how to identify if charges on a patient's account are correct.
In-depth understanding of what information is available to assist in the process, such as the medical records, chart view, MPI, etc.
In-depth understanding of collection laws pertaining to worker compensation and third party liability claims.
Become fluent and knowledgeable in the Single Billing Office environment within Epic.
Maintains a working knowledge of common billing and account resolution practices and requirements for hospital and/or clinic billing (SBO).
Knowledge of how to work a claim from beginning to end.
Learn and create in-depth knowledge of all applications used by Patient Financial Services partners such as: Epic, Agility, Connex, Kronos, OneSource, Microsoft Word, Microsoft Outlook, Claim source, On-Base, etc.
Identifies the correct filing order per department processes when multiple insurances are involved.
Responds to inquiries from patients, insurance companies, attorney offices and outside vendors via mail, phone and/or email.
Responds to inquiries regarding credit balances on Workers Compensation, Third Party Liability, Hospice, Skilled Nursing Facilities and Occupational Health accounts and initiates the refund process in the event monies are due back to the payer or patient.
Responds to Billing reviews/ inquiries from other PFS groups such as Billers, Follow-up, Cash posting and Customer Service.
Documents all encounters on appropriate patient account/claim utilizing notes.
Ensures account is updated to accurately reflect the current status.
Protects privacy and confidentiality of customers, patients and partners in accordance with Mercyhealth policies, the Code of Ethics and HIPAA laws.
Review all Work Comp, TPL and personal injury settlement requests before sending them to the Supervisor.
Work special projects and other job duties as assigned.
Verifies claims are received by the payer and follows up to obtain payment via phone calls, portal or websites.
Reviews failed claims, resolves disputed and denied claims.
Obtains and sends medical records as needed for Workers Compensation claims, Third Party Liability accounts and attorneys' offices.
Drafts appeal letters when applicable based on payer requirement in a format that is legible and relates to the denied claim.
Become familiar with ICD-10, CPT, and/or HCPCS Coding Systems as well as claim forms such as CMS-1500 and UB-04 as well as payer remittances.
Calls patients, payers and attorney offices without hesitation to obtain needed information to resolve account balances.
Identify trends with payer denials and escalates these trends to leads/supervisors.
Works with appropriate revenue cycle staff when performing account resolution functions.
Responsible to work assigned work queues, reports and spreadsheets.
Participate in department meetings, workgroup meetings, and training sessions.
Ability to adapt to change in a positive, sensitive and forward-thinking manner in demanding situations.
Maintains productivity standards as outlined in the Revenue Cycle department.