PFS Specialist II

Job Purpose

To analyze and follow up outstanding account balances and establishing acceptable payment arrangements.

Job Functions

• Process 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.
• Process 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.
• Maintain 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.
• 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.
• 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.

Required Skills & Knowledge

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.