Within Policies and Procedures, and under direct supervision, this position is responsible for researching and identifying issues within multiple computerized internal systems applications, reconciling credit balances on accounts for all lines of business, determining disposition and resolving credit balances, reconciling accounts to zero balance, processing adjustments on accounts, liability bucket reconciliation, and reconciliation between systems using a solid understanding of reimbursement c... more details
Description:
Job Summary:
Within Policies and Procedures, and under direct supervision, this position is responsible for researching and identifying issues within multiple computerized internal systems applications, reconciling credit balances on accounts for all lines of business, determining disposition and resolving credit balances, reconciling accounts to zero balance, processing adjustments on accounts, liability bucket reconciliation, and reconciliation between systems using a solid understanding of reimbursement contracts and guidelines. Also responsible for maintaining liaison between hospital and clinic locations, Health Plan, insurance companies, and other departments within the organization.
Essential Responsibilities:
Researches and follows up on all patient and insurance credit balance accounts for all lines of business in order to resolve accounts to a zero balance and provide excellent and compliant customer service to KP patients, institutional, and government payers including Medicare, and MediCal.
Identifies and reconciles accounts so that if necessary they can be escheated to the state to comply with regulatory requirements.
Reviews KP HealthConnect (EPIC) work queues or reports to determine proper course of action for credit balance resolution by preparing or reversing adjustments, initiating refund requests, reversing charges and requesting transfers, if applicable.
Analyzes explanation of benefits, attorney, insurance and other confidential documentation, including patient statements as part of account resolution.
Discusses credit balances and refunds with attorneys and insurance adjusters who represent patients and/or institutional and government payers, including Medicare, and MediCal, Follows up with written correspondence as needed with attorneys, and institutional payer representatives.
Identifies trends and root causes in undistributed payments and recommends solutions to PFS management, NCAL and SCAL Revenue Cycle management, and TPMG and SCPMG management, and regulatory compliance staff, in order to prevent future occurrences and ensure compliant actions by KP.
Analyzes Explanation of Benefits (EOBs), and remittance advices, and posts refund adjustments to the appropriate accounts consistent with KP Policies and PFS reimbursement guidelines and contracts.
Compiles documentation for submission to Accounts Payable that supports refund processing and ensures compliant KP actions and superior customer service.
Performs other related duties as assigned, including but not limited to special projects.
Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations accreditation and license requirement (if applicable), and Kaiser Permanentes policies and procedures.
Basic Qualifications:
Experience
There are three experience/education based pathways by which candidates can qualify for the position: Minimum of one (1) year recent patient accounts receivable reconciliation experience handling both Hospital and Professional Patient Accounting AND one (1) year of healthcare collector experience performing outbound insurance balance follow-up and resolution (not just inbound calls), using knowledge of patient debit balances, credit balances, procedure codes, refund procedures, cash transactions, and experience reconciling accounts to a zero balance.
2. the absence of healthcare experience, the minimum qualifications are four (4) years credit, collections, and full account reconciliation experience as a collector or credit analyst making outbound calls handling highly complex accounts and high volumes of reconciliation and collection issues that have multiple root causes and solutions.
3. Internal PFS SEIU-UHW member candidates may qualify via the PFS Career Ladder, and should consult with their supervisor and/or manager.
The Basic Computer Literacy Assessment score must be current within one (1) year (contact Local HR Office for testing). Must obtain passing score on the Basic Computer Literacy Assessment (passing score set at 75).
Internal candidates must have a minimum of two (2)years experience using KP HealthConnect Resolute or meet the substitution requirement above.
Education
High School Diploma or GED.
Basic minimum required quals OR successful completion of the PFS Career Ladder curriculum that is mapped to that position.
License, Certification, Registration
N/A
Additional Requirements:
Demonstrated Computer Agility (tested) which includes being proficient in PC Windows based environment, and an ability to use Word and Excel formulas, sorting, and other common functions (minimum test score required).
Demonstrated experience reconciling accounts to a zero balance, including all debit and credit balances, with a basic understanding of accounting transactions.
Ability to effectively communicate account circumstances and/or root causes to ASU management and PFS staff.
Demonstrated knowledge of Federal Fair Debt and Collections Act, HIPAA, NAIC.
Demonstrated knowledge of reimbursement practices by all lines of business that PFS handles (e.g.,Medicare, MediCal, Commercial, Workers Compensation, Self Funded, etc.).
Understanding of contractual allowances, capitation reimbursement, administrative adjustments and basic medical terms.
Strong interpersonal, verbal and written communication skills.
Successfully pass 10 key by touch test with minimum passing score of 5,000 gross keystrokes per hour.
Ability to perform basic mathematical computations and succinctly describe the analysis performed.
Ability to sit for long period of time.
Ability to use general office equipment including telephone, fax, copier.
Ability to work well in a team environment and within the Labor Management Partnership guidelines and effectively participate in Unit Based Teams.
Preferred Qualifications:
An ability to use Excel functions such as match, sumif, vlookup, and other data analysis spreadsheet functions as needed.
AA degree in business or certification in health or other insurance billing or collections issued by an accredited learning institution.
SUBSTITUTION: BA or BS degree in another academic area that focuses on analysis or accounting.
Notes:
On call position needs to have Healthcare insurance experience and understand debits and credits.
On call position on site replacing an FTE that is working as UPR with LMP for until February 2025.
This is an on call position, days and hours may vary.
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