Patient Financial Services Representative/Medicare

SHS South Shore Health System, Inc.; United States; Hybrid; USD 31,000 - 44,000; Full time

Job summary

South Shore Health is seeking a Patient Financial Services Representative to ensure efficient and professional handling of the financial aspects of patient care, including Medicare collections and Epic Billing System use for claims submissions and follow-up. The role involves resolving denials, communicating with payers, and helping maintain accurate account documentation.

Hybrid or remote work options may be available after training, with typical hours Mon–Fri.

Qualifications

• High school diploma or equivalent preferred.
• Minimum 2 years hospital/physician billing experience.
• Knowledge of healthcare billing, insurance plans, codes, and reimbursement methodologies.
• Proficiency in data entry and basic computer skills, including Microsoft Office Suite.
• Strong organizational and multitasking skills; strong interpersonal and communication skills; strong analytical and independent decision making skills.
• Hybrid or remote work options may be available; schedule M-F 7:00 AM - 3:30 PM; Hybrid option after training.

Responsibilities

• Maintains up to date knowledge of all Federal, State and Insurance specific billing regulations, policies, procedures and code sets.
• Notify manager of any changes that would affect claim submission.
• Protect patient privacy and confidentiality in accordance with HIPAA regulations.
• Maintain compliance with federal, state, payer, and organizational billing regulations.
• Monitor payer policy updates and communicate changes that may impact billing, collections, denials, or reimbursement processes.
• Evaluates daily claim file using Claim Edit and Charge Review Work queues for submission of UB-04 and 1500 claim forms.
• Initiate claim corrections as defined payer regulation and hospital policy.
• Work external claim edits from Clearinghouse and resubmit claims through EPIC.
• Initiate collection of aged accounts receivable through Epic work queues while prioritizing accounts based on aging criteria.
• Unresolved and incomplete accounts require insurance company contact by phone, e-mail or designated web site to resolve outstanding balances.
• Collaborate with denial management staff for accounts that require clinical intervention for an appeal process.
• Collaborate with clinical departments, patient access and other departments as needed to resolve account issues.
• Generate technical appeals as needed for account resolution.
• Provide to manager a detail account history for any account that is considered uncollectable.
• Document all actions taken within the EPIC account notes section and/or follow up/denial activities note section. Documentation is required at least every 30 days for all accounts requiring follow-up.
• Escalates payer related issues to Provider Representative for resolution and participate in monthly meetings.
• Must maintain defined quality and productivity measures.
• Evaluate current processes, identify denial or payment trends and elevate to Management.
• Handle payer 277 rejections and resubmit through EPIC system.
• Reconcile account balances and ensure appropriate adjustments are applied according to established policies.
• Review credits work queues for resolution of overpayments and undistributed payments.
• Review credit balances in assigned work queues and request refunds or payer retraction as needed.
• Communicate with patients as needed for additional insurance or other information needed in order to process a claim.
• Generate phone calls or letters as needed to obtain necessary insurance or other related information, prior to an account being placed in self pay.
• Obtain proper verification of predefined patient demographic information and maintain documentation in order to verify identity.
• Embraces technological solutions to work processes and practices.
• Uses the Mytime payroll system to enter time worked, sick days, vacations and holidays.
• Uses Epic functionality
• Uses MS Outlook as a communication tool
• Access provider web sites for verification of accounts.
• Access Sharepoint and OneDrive for stored files.
• Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.
• Successfully answers safety questions in the annual mandatory education packet.
• Maintains a neat, organized work environment.
• Adheres to respiratory etiquette guidelines.
• Assist with identifying workflow improvements to enhance operational efficiency.
• Assist leadership with special projects, audits, and process improvement initiatives.
• Other duties as assigned by Managements in accordance with department needs.

Education

High school graduate

Job description

Patient Financial Services Representatives are responsible for ensuring the financial aspect of the patient’s healthcare is handled efficiently and professionally. Medicare collection and knowledge highly desired. You will utilize the Epic Billing System to prepare, submit and follow up on compliant Hospital and Physician insurance claims to ensure payment. Communicate with insurance companies to resolve any claim denials or discrepancies.

Compensation Pay Range: $22.20 - $31.75

ESSENTIAL FUNCTIONS

1. Maintains up to date knowledge of all Federal, State and Insurance specific billing regulations, policies, procedures and code sets.

   • a - Notifies manager of any changes that would affect claim submission
   • b - Protect patient privacy and confidentiality in accordance with HIPAA regulations
   • c- Maintain compliance with federal, state, payer, and organizational billing regulations.
   • d- Monitor payer policy updates and communicate changes that may impact billing, collections, denials, or reimbursement processes.

2. Evaluates daily claim file using Claim Edit and Charge Review Work queues for submission of UB-04 and 1500 claim forms.

   • a - Initiate claim corrections as defined payer regulation and hospital policy.
   • b - Works external claim edits from Clearinghouse and resubmits claims through EPIC

3. Initiate collection of aged accounts receivable through Epic work queues while prioritizing accounts based on organizational goals and aging criteria.

   • a – Unresolved and incomplete accounts require insurance company contact by phone, e-mail or designated web site to resolve outstanding balances.
   • b - Collaborate with denial management staff for accounts that require clinical intervention for an appeal process.
   • c- Collaborate with clinical departments, patient access and other departments are needed to resolve account issues.
   • d- Generate technical appeals as needed for account resolution.
   • e - Provide to manager a detail account history for any account that is considered uncollectable.
   • f - Document all actions taken within the EPIC account notes section and/or follow up/denial activities note section. Documentation is required at least every 30 days for all accounts requiring follow-up.
   • g - Escalates payer related issues to Provider Representative for resolution and participate in monthly meetings.
   • h - Must maintain defined quality and productivity measures.
   • i - Evaluate current processes, identify denial or payment trends and elevate to Management.
   • j - Handle payer 277 rejections and resubmit through EPIC system.
   • k - Reconcile account balances and ensure appropriate adjustments are applied according to established policies.

4. Review credits work queues for resolution of overpayments and undistributed payments.

   • a - Review credit balances in assigned work queues and request refunds or payer retraction as needed.

5. Communicate with patients as needed for additional insurance or other information needed in order to process a claim.

   • a - Generate phone calls or letters as needed to obtain necessary insurance or other related information, prior to an account being placed in self pay.
   • b - Obtain proper verification of predefined patient demographic information and maintain documentation in order to verify identity.

6. Embraces technological solutions to work processes and practices.

   • a - Uses the Mytime payroll system to enter time worked, sick days, vacations and holidays.
   • b - Uses Epic functionality
   • c - Uses MS Outlook as a communication tool
   • d - Access provider web sites for verification of accounts.
   • e - Access Sharepoint and OneDrive for stored files.

7. Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.

   • a - Successfully answers safety questions in the annual mandatory education packet.
   • b - Maintains a neat, organized work environment.
   • c - Adheres to respiratory etiquette guidelines.

8. Assist with identifying workflow improvements to enhance operational efficiency.

   • a- Assist leadership with special projects, audits, and process improvement initiatives.

9. Other duties as assigned by Managements in accordance with department needs.

JOB REQUIREMENTS

• Minimum Education - Preferred High school graduate or above preferred.
• Minimum Work Experience 2 years of hospital and/or physicians billing preferred.
• Required additional Knowledge and Abilities Knowledge of healthcare billing, insurance plans, codes, and reimbursement methodologies Proficiency in data entry and basic computer skills, including Microsoft Office Suite. Excellent organizational and multitasking skills Strong interpersonal and communication skills Strong analytical and independent decision making skills.
• Hybrid or remote work options may be available M-F 7:00 AM - 3:30 PM. Hybrid option after training.
• Responsibilities if Required: Education if Required:
• License/Registration/Certification Requirements:

South Shore Health is a not-for-profit, charitable health system offering primary and specialty care, hospital care, home health and community care, emergency and urgent care, and preventative and wellness services. We are the largest independent health system in southeastern Massachusetts. South Shore Health brings together like-minded people who work “As One” toward a common goal of providing exceptional care the people of our region deserve. We unite top-caliber talent, technology, and service with the wishes and personal needs of patients and their families to develop individualized treatment plans.