The Collector Appeal Specialist is responsible for accurately processing inpatient and out-patient claims to third party payers and private pays, following all mandated billing guidelines. Responsible for ensuring timely filing and guidelines are met; provided quality control checks on paper and electronic claims; process tracers, denial and related correspondence; initiate appeals; compose and submit appeal letters specific challengeable denial issues consistent with the most update American Medical Association Current Procedural Terminology. Must demonstrate a positive demeanor, good verbal and written skills, and must be professional in both appearance and approach. Will maintain consistent productivity standards as appropriate for their unit as well as maintain an average of 90% (score 9.0) or better on Quality Reviews. The Professional Billing Refund Collector is responsible for accurately reviewing credit balances and processing adjustments, transfers and refunds as needed. Helps in billing operations by providing support and research of misapplied payments. Works as a member of the billing team to provide smooth operational flow resulting in optimum customer (internal/external) satisfaction and effective/efficient processes. TYPE OF SUPERVISION RECEIVED: Direct supervision required. Daily, weekly and/or monthly Unit meetings may be required. Direct review of daily production and other production-based reports to validate staff usage needs, portfolio reduction efforts, customer services and staff morale.

Essential Duties:

• TECHNICAL DUTIES
• Billing Tasks Analyzes and determines which billing procedure should be followed, based upon the type of financial class, e.g., contracts, private insurance carrier, HMOs, government programs, Federal/State/Local, Self-Pay accounts in conjunction with type of billing: transplants, grants, trauma and indigent programs, LOAs, MSP billing. Analyzes the information submitted by the various departments for billing and the appropriate documentation required for processing a claim form whether submitted hard copy or electronically. Understands all billing vendors used by the MSO - CBO. Contacts by telephone or e-mail the appropriate departments to obtain the required information needed to process a claim. Analyzes the pre-printed information on the claim form(s) or billing system to ensure that it is accurate and consistent with other information contained in Cerner or patient accounting system and makes corrections as necessary. Edits charges on the claim form(s) or billing system for which departmental and payer guidelines stipulate should not be billed to the sponsor. Recomputes the total amount due prior to submitting the claim e.g. edits unbillable charges for all payors. Reviews the claim forms to identify sensitive diagnosis information and follows guidelines and procedures established by the department to maintain patient confidentiality. Review Charges/Encounter Forms for accurate billing information and assure that data fields are correct. Inputs all the required information needed to complete the claim, edit accordingly and submit either hardcopy or electronically, with all the required documentation. i.e. authorizations, reimbursement based on LOAs, medical records, sterilization consent forms, treatment authorization requests, authorizations, hysterectomy consent forms, Inpatient/Outpatient TARs and SARs, and ABNs, and CMS certs and recerts. Obtains and reviews the medical record or on-line reports for additional documentation to be attached to hardcopy claim forms. Transmits claims via electronic vendor, once all corrections and adjustments have been processed. Submits completed claim forms to appropriate carriers with all required supplemental documentation Submits hard copy claims via certified mail. Works and resolves reject for all assigned claims daily Bills for late charges as needed. Communicates identified billing issues and trends to Supervisor and Billing Manager in a timely manner. Communicates issues with claim scrubber edits to Supervisor and Billing Manager in a timely manner. Communicates issues that impact bill holds with outside vendors: i.e. CMRE/RSI Collection Agencies to reporting manager Utilize CPT, ICD-10-CM, HCPCS, Insurance Directories and other insurance books as well as Cerner, AIDX/GE and other systems to solve billing issues and problems. Utilize all systems as applicable. etc. Complete tasks based on assigned priority matrix.
• Follow Up Collections Follow-up and collect on accounts for all payors, including Medicare, Medi-Cal, commercial, guarantor, and other contracted payors. Primary follow-up assignment is to facilitate payment for accounts previously billed. Review each patients case, correspondence, and current computer data to determine possible payment problems. Maintain portfolio of such accounts with optimum cash collections, adjustments and closures. Perform follow-up on all outstanding insurance claims. Document all activity. Manage and process assigned computerized (i.e., ETM, etc.) or manual worklist in a timely manner to ensure that MSO CBO achieves its overall collection standards and quality measures. Call appropriate third-party contacts and establish specific reimbursement status, i.e. reason for any discrepancy between expected and actual reimbursement amount and date of issuance. Be aware of courtesy rates and/or courtesy adjustments. Adjustments / Write-Offs / Updates Submits necessary adjustments using the correct debit or credit transaction in order to correct account balance and/or claim totals prior to submission. Submits adjustments with appropriate codes. When circumstances warrant, transfers all or parts of a patient account charges to the correct account. Submits charge corrections and/or combines charges correctly via patient accounting system. Updates case / payer data and documents the reason for the updates; requests rebills as necessary. Submits adjustment requests to immediate Supervisor for review and approval. Applies proficiency in understanding and applying contractual terms of our Managed Care contracts (i.e., PPO, HMO, EPO, POS, Medi-Cal, Medicare, etc.). Applies knowledge of Cerner, AIDX/GE and other systems Demonstrates knowledge in various payor websites. System Folder Notes / Account Documentation Documents claim bill date, billed amounts, billing address, billing attachments, invoice number, expected payment, contractual amount, received payments, actual transplant date(s), type of transplant, pre and post periods for transplant days, and all pertinent billing data relevant to billing the claim. Documents in a clear, concise and grammatically correct manner in system folder notes. Uses appropriate collector comment codes.
• Meets Production and Quality Review Standards set by Team Supervisor and Billing Manager. Reviews patient accounts and back up documentation to determine the nature and extent of delinquency problems and any actions taken by patients or third-party payors. Communicates with billing office staff to obtain additional information as needed. Provides feedback and guidance to office staff regarding coding, claim appeals, authorizations and diagnosis requirements.
• Contacts government and third-party payors and/or patients to facilitate timely payment of past due charges; arranges alternative settlement plans as needed. Responds to third-party payors or patient inquiries in a timely manner. Reviews Explanation of Benefits from government and third-party payors to determine if payment was made correctly and if denials can be re-billed.
• Identifies problem delinquencies and recommends appropriate course of action, such as referral to outside collection agency, legal action or write off. Requests transfers and/or adjusts patient accounts; Requests small balance write offs. Requests necessary adjustments with appropriate payment/adjustment codes, using the correct debit or credit transaction, in order to correct account balance and/or claim totals and to assure the account balance is correct when the refund is released.
• Prepares, analyzes and maintains records and reports documenting the status and amount of past due accounts and the timing and nature of their disposition. Updates billing system, GE Centricity Business (GECB) with clear, detailed, concise ETM Task notes regarding activity related to resolution of balances, i.e. claim status, payment pending, adjustments needed, etc. Reviews own work prior to taking appropriate action.
• Attends seminars and professional association meetings; reads pertinent literature to maintain current knowledge of collection policies and procedures and related legislation.
• Works off various ad hoc reports for special projects, as needed and directed. Reviews and responds to claim edits and eCommerce edits daily.
• Reviews payment transactions and researches payment correction requests. Processes adjustments, payment corrections and transfers where applicable. Researches misapplied payments. Audits patient accounts to determine appropriate action, i.e. adjustments, payment corrections. Verifies patient and insurance responsibility.
• Updates billing system, GE Centricity Business (GECB) with clear, detailed, concise ETM Task notes regarding activity related to resolution of credit balances, i.e. payment transfers, adjustments, and/or refund requests, etc. Reviews own work prior to taking appropriate action to resolve credit, i.e. payment transfers, adjustments or refund requests.
• Accesses and works off credit balance views in ETM in GECB (billing system) daily. Works off various ad hoc reports for special projects, as needed and directed.
• Applies knowledge of GECB, Cerner, MARS Refunds App and daily ETM views to review and resolve credit balances. Prioritizes working credit balances based on age of credit, in order to comply with the Office of Compliances Policy on Credit Balances.
• Stays informed of new developments and technologies by reading journals and other pertinent publications, maintaining contact with vendors, and participating in professional organizations, meetings and seminars. Performs other duties as assigned.
• OTHER DUTIES Miscellaneous Assists in special projects or other duties as assigned. Meetings, general support to other areas and office activities. Attends training classes. Assists in training co-workers if needed

Required Qualifications:

• Req High school or equivalent

• Req Experience with medical services collections for any combination of payors (Medicare, Medi-Cal/Caid, HMO, PPO, Commercial, and Private Pay).

• Req Excellent communication skills both written and oral, detail knowledge of applicable collection laws/policies/principles/etc., governing collection efforts, problem identification and resolution, insurance, medical terminology, and reimbursement procedures
• Req Expert skill-level in specialty area.
• Req Experience in computing environments.
• Req User support experience with servers, operating systems, workstations, networks, LANs and network software

Preferred Qualifications:

• Pref 2 years Medical services collections and computerized billing systems such as IDX. *Combined education/experience as substitute for minimum experience.

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

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About University of Southern California (USC)

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