Revenue Cycle Rep

In 2020, united in a fierce commitment to deliver the highest quality care and exceptional patient experience, Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care, including 11 hospitals and nearly 5,000 physicians and providers. Together, we are empowered to make an even greater impact on the health and well-being of our communities.      

CHI Franciscan and Virginia Mason are now united to build the future of patient-centered care across the Pacific Northwest. That means a seamlessly connected system offering quality care close to home. From basic health needs to the most complex, highly specialized care, our patients can count on us to meet their needs with convenient access to the region’s most prestigious experts and innovative treatments and technologies. 

Franciscan Medical Group, as part of Virginia Mason Franciscan Health, is currently looking for a full-time Revenue Cycle Rep for the fast-paced Franciscan Billing team in Tacoma, WA. 5 days a week and no weekends or organizationally recognized holidays required. 

Job Summary:

This job is responsible for performing all related revenue cycle processing activities for Durable Medical Equipment (DME) and retail pharmacy in accordance with established standards, guidelines and requirements.  An incumbent facilitates patient satisfaction through timely and accurate maintenance of patient accounts, including assistance with billing, third-party payments, adjustments, information verification and records maintenance.  Work is heavily focused on following up on insurance rejections/denials and accounts receivable to maximize revenues.  An incumbent responds to all information requests from payers and traces all claims to those payers making sure they have been paid or denied appropriately and in a timely manner.  

Work also includes: 1) submitting claims to government agencies, medical service bureaus and insurance companies; 2) posting insurance and patient payments; 3) researching/resolving insurance and patient credit balances; 4) handling customer service calls and responding to patient queries; and 4) coordinating monthly DME equipment renewals.  

Work requires an understanding of DME/pharmacy medical billing/reimbursement requirements, charge capture/cash posting/claims processes and government/commercial insurance reimbursement terms, remittance advice details and contractual/other adjustments.  Attention to detail, the ability to accurately and timely troubleshoot/resolve (within position scope) issues that have a potential impact on revenues are also required.  

Essential Duties: 

Communicates with insurance payers regarding insurance rejections/denials and to resolve unpaid insurance accounts receivable; makes necessary corrections in the practice management system to ensure appropriate reimbursement is received for all FMG providers.

• Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding, denied and/or underpaid using accurate and supported reasoning based on EOBs, reimbursement, and payer specific requirements.
• Researches denials, gathering supporting documentation and drafting appeal letters explaining why denial should be reversed; resubmits claims with necessary information when requested through paper or electronic methods. 
• Applies a thorough understanding/interpretation of Explanation of Benefits (EOBs) and remittance advices, including when and how to ensure that correct and appropriate payment has been received.
• Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.

Submits claims to government agencies, medical service bureaus and insurance companies ensuring that accounts are billed appropriately by auditing charges to ensure accurate procedure codes, billing data and patient information submitted.

• Acts as a resource to physicians, providers, administrators and patients regarding health insurance claim policies, procedures and requirements; responds to inquiries from agencies, bureaus and insurance companies to assist in the claim payment process. 
• Reviews claims for all necessary requirements for billing, including complete patient and insurance information; completes paper claim processing in a timely and accurate manner; submits claims to secondary insurers as appropriate.
• Notifies Supervisor of claim edits that could be reduced/eliminated through system modifications and/or communication and feedback to the department/clinic or other areas.
• Notifies Supervisor of additional claim edits that when added may reduce denials and result in prompt payment for the organization. 
• Notifies Supervisor of claim submission requirement changes and electronic billing errors.
• Completes payer specific edits using knowledge of payer reimbursement methodologies or government regulations.

Serves as liaison between patients and clinic staff on claims, billing questions or insurance-related issues within scope of position.  

• Provides feedback and in-service training to retail pharmacy and hospital staff with respect to billing/documentation requirements and restrictions on supplies and equipment. 
• Accurately and timely posts private payments, insurance payments, disallows and/or denials to appropriate patient account, 
• Calculates patient responsibility, interpret explanation of benefit message codes, identify payment discrepancies by contacting insurance carrier and determining if rebilling is necessary.
• Interprets and communicates information regarding credit policies and procedures, billing practices, insurance submission and out-of-pocket patient responsibility. 
• Processes patient, clinic and insurance correspondence, including requests for refunds and collections when warranted.

Coordinates monthly renewals of all rental DME equipment. 

• Monitors rental data to identify expiration dates based on established length of need dates; contacts patient prior to expiration date to confirm that equipment is no longer needed; faxes requests to physician for rental extensions as needed.
• Notifies departments to arrange for pickup of unneeded rental equipment.

Reviews and posts payments and write-off/adjustments from insurance and patients.  

• Reviews Explanation of Benefits (EOBs)/ Electronic Remittance Advice (ERAs), payments, adjustments, insurance contracts and contracting system, insurance benefits, and all account comments; applies knowledge of payer contracts and experience with insurance reviews to gather additional information as necessary. 
• Posts and tracks electronic funds transfer (EFT) information and validates EFTs for accuracy; ensures deposits balance to posting and resolves or escalates issues as appropriate. 
• Follows write-off approval protocols for non-routine adjustments.
• Completes daily posting log and quarterly cash handling audits and reports findings to Supervisor. 
• Completes accurate batch balancing and reporting activities; research errors, record adjustments to proper accounts and determine the appropriate destination for unidentified funds. 

Identifies and researches unusual, complex or escalated issues as assigned; applies problem-solving and critical thinking skills as necessary to resolve issues within the scope of position authority or to escalate following established procedures. 

• Notifies Supervisor/Manager of ongoing issues and concerns as appropriate.

Documents all activities and findings in accordance with established policies and procedures; ensures the integrity of all account documentation; maintains confidentiality of medical records. 

• Meets quality assurance and productivity standards for timely and accurate revenue cycle-related activities within position scope and in accordance with organizational policies and procedures. 
• Accurately documents patient accounts of all actions taken in billing system.

Maintains current knowledge of internal, industry, and government regulations as applicable to assigned function.

• Has knowledge of, and is compliant with, government regulations including "signature on file" requirements, compliance program, HIPAA, etc.
• Applies current knowledge of current/revised regulatory requirements (e.g. Medicare/Medicaid) relating to the billing of durable medical equipment (e.g. orthotics, prosthetics and related products) and retail pharmacy medications. 
• Understands detailed billing requirements, denial reason codes, and insurance follow-up practices; provides information regarding implementation of new codes and/or revision of charge documents as appropriate.
• Applies current knowledge of government/commercial insurance reimbursement terms, contractual and/or other adjustments and remittance advice details.

Performs related duties as required.                                                 

Education/Requirements:

• Two years of revenue cycle or related work experience that demonstrates attainment of the requisite job knowledge and abilities;OR
• Post-high school education in a field (e.g. medical billing) that would demonstrate attainment of the requisite job knowledge/abilities may be substituted, on a month-for-month basis, for one year of the experience requirement.