PFS Specialist II - Medicaid Collector

JOB PURPOSE OR MISSION: To analyze and follow up outstanding account balances and establishing acceptable payment arrangements.

PERFORMANCE CRITERIA

CRITERIA A: Everyday Excellence Values

Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.

PERFORMANCE STANDARDS:

• Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
• Takes initiative in living our Everyday Excellence values and vital signs.
• Takes initiative in identifying customer needs before the customer asks.
• Participates in teamwork willingly and with enthusiasm.
• Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
• Keeps customers informed, answers customer questions and anticipates information needs of customers.

CRITERIA B: Corporate Compliance

Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines and the GHS Corporate Compliance Guidelines.

PERFORMANCE STANDARDS

• Practices diligence in fulfilling the regulatory and legal requirements of the position and department.
• Maintains accurate and reliable patient/organizational records.
• Maintains professional relationships with appropriate officials; communicates honesty and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.

CRITERIA C: Personal Achievement

Employee demonstrates initiative in achieving work goals and meeting personal objectives.

PERFORMANCE STANDARDS

• Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
• Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
• Upholds the ethical standards of the organization.

CRITERIA D: Performance Improvement

Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.

PERFORMANCE STANDARDS

• Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
• Initiates or redesigns to continuously improve work processes.
• Contributes ideas and suggestions to improve approaches to work processes.
• Willingly participates in organization and/or department quality initiatives.

CRITERIA E: Cost Management

Employee demonstrates effective cost management practices.

PERFORMANCE STANDARDS

• Effectively manages time and resources.
• Makes conscious effort to effectively utilize the resources of the organization — material, human, and financial.
• Consistently looks for and uses resource saving processes.

CRITERIA F: Patient & Employee Safety

Employee actively participates in and demonstrates effective patient and employee safety practices.

PERFORMANCE STANDARDS

• Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
• Employee proactively reports errors, potential errors, injuries or potential injuries.
• Employee demonstrates departmental specific patient and employee safety standards at all times.
• Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.

JOB FUNCTIONS

ESSENTIAL JOB FUNCTIONS include, but are not limited to:

1. Processes claims populating into Ambulatory Claims Manager (ACM)

• Resolve Invalid and Rejected Claims populating into the list within 5 days.
• Documents the system with notes on current status received and takes appropriate action.
• Refers delinquent responses and new denials to management.

2. Processes hard copy claims for payment

• Obtains Explanation of Benefits (EOBs) for coordination of coverage to attach to Subsequent claims to Secondary and Tertiary carriers.
• Reviews claim for timely filing guidelines, fee schedule reimbursement, etc prior to mailing claims.
• Refers any issues to management.

3. Maintains Practice Responses to communications

• Creates and responds to RAI (Request for Additional Information) and/or Spreadsheet.
• Monitors any lack of responses.
• Refers any issues to management.

4. Special projects

• Receives and resolves “unable to bill” claims by reviewing the system for copy of insurance card, correct address, policy number and phone number of insurance carrier for Hospitalist Group.
• Investigates any reports delivered by management to monitor denials.

5. Performs all other duties as assigned.

EXPERIENCE REQUIREMENTS: Prior experience in all phases of Business Office operations and Insurance Collections.

EDUCATIONAL REQUIREMENTS: High School Diploma or GED preferred.

SPECIAL SKILL, LICENSE AND KNOWLEDGE REQUIREMENTS: Must have excellent understanding and knowledge of Commercial Insurance.

HIPAA REQUIREMENTS: Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: paper medical record without limitation, patient demographics, lab results, patient financial and 3rd party billing information, patients related complaints, information related to patient location.

SAFETY REQUIREMENTS: Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: incident reporting, exposure control plan, hand washing for all age groups.