Medical Collector (Healthcare)
Planned Parenthood of Orange and San Bernardino Counties has a full-time opportunity for a Medical Collector in Anaheim, CA.
The Revenue Recovery Analyst identifies, collects, and determines root causes of underpaid claims by auditing payor performance and analyzing actual payments of payors to ensure contract compliance, which is operationally critical and sensitive in nature. The Revenue Recovery Analyst will support the RCM collection team with training and escalated claim follow-up. The Revenue Recovery Analyst performs payment variance deep dive and review activities related to the incorrect processing of claims across PPOSBC. This position will focus on the resubmission, reprocessing, and correcting of denied or rejected/exhausted insurance claims (2nd Level) as well as all high-volume facilities, top payors, and high-level, complex claim issues.
At PPOSBC, we understand the importance of a well-rounded benefits program and are dedicated to providing you with unique benefits that meet the needs of you and your family. We are proud to offer a range of plans that help protect you in the case of illness or injury including:
- A competitive benefits package including medical, dental, and vision coverage for you and eligible dependents, life insurance, and long term disability.
- Benefits coverage starts after one full month of employment!
- Generous vacation, sick, and holiday benefits!
- Generous 401(k) matching contributions and more!
- To view our detailed benefits guide, please visit our career site at www.pposbccareers.org
Responsibilities
Essential functions encompass the required tasks, duties, and responsibilities performed as part of the job and the reason the job exists.
- Utilize independent judgment and exercise discretion to ensure timely review and auditing of underpaid claims.
- Analyze, collect underpayments, and resolve claims with discrepancies from expected payment to ensure payors are in payment compliance with their contracted terms.
- Compile billing and payor documentation to create training documents.
- Initiate and follow through with all relevant parties to ensure corrective actions are implemented (i.e., pursue underpayments, adjust expected reimbursement, address billing issues, negotiate settlements, etc.) according to payor specific processes.
- Respond to payment discrepancies by creating appeal letters and articulating contract provisions to representatives from third-party payors. Work directly with payor to recover payments.
- Quantify payor trends and maintain productivity and accuracy standards in a highly challenging environment. Prepare second-level appeals, recoveries, and potential settlements.
- Ability to extrapolate complex claims data and payer information to accurately report trends and payor behaviors.
- Develops dashboards and reports on key performance indicators, metrics, data points, and formulas to support management objectives.
- Extract, load, and reconcile large data sets from multiple system platforms and sources.
- Review data to determine operational impacts, trends, and areas for improvement.
- Follow up on claim submissions to determine batch acceptance, rejection, or denial in a timely manner.
- Research, correct, resolve, resubmit, and appeal denied claims/services. Correspond with insurance companies to resolve issues; submit appeals per payor requirements.
- Maintains collections rate for assigned payors at or above 70% of allowed charges.
- Communicate with RCM leadership about payor updates, changes, and requirements.
- Sort and file paperwork from health plans, patient charts, and payment correspondence.
- Update Division of Financial Risk (DOFR) quarterly with staff and report issues to Manager.
- Support the team in their efforts to provide payors with information or documentation necessary for payment of claims and/or any other account follow-up required to recover payment within a required timeframe.
Non-Essential Functions:
- Other duties as assigned.
CORE COMPETENCIES – WE CARE:
- Welcoming: Anticipates customer requirements and gives high priority to customer satisfaction and service. Handles problems quickly and efficiently. Maintains a pleasant, positive and professional approach. Embraces opportunities to help team members, stakeholders, and other departments.
- Equitable: Creating equitable access and opportunity for all through education, practicing inclusive behavior, elevating others' voices, creating spaces for honest conversation, and listening without judgment. Values and uplifts our collective diversity within in our agency.
- Confidential: Respects the information shared by our patients, employees, and vendors and maintains appropriate confidentiality. Follows all policies and laws that protect private & privileged information.
- Accessible: Is available and approachable to others, open-minded, fair and non-defensive. Appreciates constructive feedback and is a team player. Demonstrates good listening skills.
- Respectful: Values diversity and treats everyone with dignity and courtesy. Dependable and courteous of other people's time and commitments.
- Empathetic: Demonstrates interest and understanding in other people's feelings, attitudes and reasoning. Maintains an open and non-judgmental demeanor that is patient, flexible, and understanding.
Qualifications
Licensure and/or Certification Requirements:
- Coding certificate is a plus.
Minimum Education:
- Associate's Degree required in related field.
- Bachelor's Degree preferred or equivalent experience in related field.
Minimum Work Experience:
- A minimum of 5 years of experience as a medical biller/claims follow-up specialist or collections specialist in an outpatient medical setting (non-hospital) in primary care (required), family planning, ob-gyn, and related surgeries.
- Advanced knowledge of medical terminology and common industry abbreviations, anatomy and physiology, pharmacology, and pathophysiology.
- Knowledge of payor guidelines, industry billing, and coding standards, and Medi-Cal denials reason codes.
- Computer database management (electronic practice management system). EclinicalWorks/NextGen experience preferred.
- A minimum of 5 years of experience with insurance billing, coding, and reimbursement procedures.
- A minimum of 5 years of experience with HIPAA 5010 transaction standards.
- A minimum of 5 years of experience claims follow-up/appeals and health plan Accounts Receivable management for specific payors.
Other Requirements:
- Ability to successfully communicate with payors, including insurance companies, health plans, and medical groups, regarding unpaid claims. Knowledge of CPT4/HCPCS and ICD10 coding and billing guidelines.
- Advanced knowledge of Medi-Cal Managed Care, Commercial Payors, Medi-Cal, FPACT, & PE.
- Advanced knowledge of health care and Medi-Cal denial reasons, denials codes and descriptions, and standard denial resolution practices.
- Ability to judgment independently as to compare actual reimbursement to expected reimbursement, reviewing managed care contract terms, claims billing and clinical information to effectively reconcile underpaid accounts and maintain documentation to support this activity.
- Expert knowledge of health care reimbursement and contracting and the use of deductive reasoning, negotiating skills, and collaborative skills to uncover and recover payment discrepancies in a complex system and complex payor environment.
- Strong verbal and written communication skills are essential.
- Ability to demonstrate mature judgment, initiative, and critical thinking.
- Strong follow-up skills and time management with internal and customer stakeholders.
- Ability to maintain confidentiality.
- Accuracy and attention to detail is essential.
- Availability to work flexible hours, including weekends.
Agency Standard Requirements:
- Strong commitment to quality healthcare and excellent customer service is required.
- Must thrive in a fast-paced, rigorous environment with changing priorities.
- Ability to meet deadlines and work under pressure.
- Must demonstrate high-level computer skills, including Microsoft Word, Excel, and Outlook. Electronic medical records experience may also be required.
- This position requires travel to other sites and locations; if using a personal vehicle to meet this requirement, a valid CA driver's license and current auto insurance in compliance with the minimum requirements of CA vehicle code are required.
- Abortion patients are cared for at each of our health centers and in part through the administrative, support, and other non-clinical services provided at all PPOSBC locations and by all PPOSBC employees, and supporting these critical services is an essential job duty and fundamental responsibility of all employees.
