The Payment Specialist works independently and is responsible for the analysis and interpretation of complex contract language to identify and determine maximum reimbursement. Applies independent judgment and knowledge to audit third-party payer payment disputes. Documents and/or notifies management of preventive measures in response to payment trends identified through analysis of claims denial data. Works with management staff identifying corrective measures necessary to resolve denial problems.
Duties & Responsibilities:
Ability to research and use critical thinking skills in contract interpretation of third party payers to determine the appropriate maximum reimbursement.
Ability to apply knowledge of state and federal regulations in regards to correct payment practices.
Ability to utilize appropriate resources, both hard-copy and online, to facilitate correct payment.
Ability to research and follow-up on insurance and patient refunds to ensure accurate account balances.
Ability to document precise notes in the financial system of all transactions and correspondence.
Able to be at work and on time, follow organization rules and procedures and directions from a Coordinator/Lead or other member of the Management staff.
Able to adhere to all confidentiality policies and procedures and carries out all tasks in a pleasant and respectful manner.
Ability to make suggestions for enhancements throughout the department and continually seeks opportunities to improve current policies, procedures and practices.
Ability to use critical thinking while reviewing billing and collection notes in the financial computer system to ensure that the appropriate action is taken within the billing and collection process to ensure correct hospital reimbursement.
Candidate with a minimum of 3 years’ experience in Hospital Revenue Cycle including HMO, PPO, Medicare Advantage and Managed- Medi-Cal collections and payment review
Analyze Payer EOB's, RA's and system calculations to determine cause of payment discrepancies
Understanding of managed care hospital contract terms including exclusions, lesser of and not to exceed, etc. language.
Current experience with Medicare IPPS & OPPS payment methodologies