GENERAL SUMMARY:

Responsible for identifying underpaid payment discrepancies for Managed Care, Government and Commercial payor plans when payments posted do not meet the expected payment as modeled in the patient accounting system. Expected payments are based on contracts with insurance companies or government mandated amounts.

ESSENTIAL DUTIES:

1. Analyze accounts daily from the payment discrepancy work queues to validate payment discrepancies against contract terms.

2. Interpret and calculate payer contract reimbursement methodology.

3. Assign the appropriate reason code and root cause reason for the discrepancy along with system notes detailing the issue, including all actions taken to resolve the discrepancy.

4. Resolve non-payment discrepancies by forwarding all non-underpaid payment discrepancies to the appropriate departments for resolution.

5. Reconcile account balances, post adjustments as needed.

6. Contact insurance companies on underpaid accounts to collect the underpaid portion of the claim.

7. Submit reconsideration letters online or certified mail for underpaid accounts dependent upon payors’ process.

8. Perform timely follow-up; Prepare and submit payer packages as directed on unresolved discrepancies.

9. Trend and escalate systemic contract payment discrepancies for prompt resolution.

10. Validate, record and report underpayment recoveries.

11. Other Related Duties as assigned.

This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.

STANDARD REQUIREMENTS:

1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.

2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.

3. Supports and adheres to all Beaumont Health’s customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.

4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.

5. Supports and participates in a collaborative team-oriented environment – cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.

6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules – including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.

7. Completes all required compliance standards that may be department specific and/or identified by the organization.

8. Maintains current licensure, registration and/or certification, as applicable, at all times.

STANDARD QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

A. Education / Training:

• High School diploma or GED.

B. Work Experience:

• Minimum one year related experience preferred.

• Relevant education may substitute experience requirement.

• Billing experience, knowledge of insurance payment methodologies or knowledge of revenue cycle, a plus.

C. Certification, Licensure, Registration:

• HFMA Certified Revenue Cycle Specialist certification within 6 months.

D. Other Qualifications:

• Requires critical thinking, problem solving and decisive judgment skills.

• Must be able to perform basic mathematical calculations.

• Ability to work with minimal supervision and must possess excellent time management and organizational skills.

• Must be able to work in a stressful environment and take appropriate action. Communicates clearly and concisely, verbally and in writing. Requires knowledge of computer systems and operating systems.

• Must demonstrate proficiency of Microsoft Office applications. EPIC experience a plus.

• Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.