PAYER ANALYST REPORT & RECOVERY - NON-GOVERNMENT ACCOUNTS

Overview

Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community.

Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs.

Position Summary :

This position is responsible for ensuring all billing and collecting of claims is completed accurately, timely and according to all guidelines and requirements to ensure proper reimbursement. Follows-up and follows-through to resolve underpaid and denied accounts. Utilizes system to follow-up on underpayments and denials to secure payment. Demonstrates extraordinary commitment to excellence by adhering to departmental excellence criteria.

Major Position Responsibilities :

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.

• Maintains a safe, clean working environment, including unit based safety and infection control requirements.
• Responsible for meeting collection goals established by the department leadership.
• Utilizes QMS to reach daily and weekly goals.
• Represents TCMC when claims need to be researched with insurance companies by phone, Internet to verify payment, denial, and patient or guarantor eligibility.
• Represents TCMC when claims need to be researched with insurance companies by phone, Internet to verify payment, denial, and patient or guarantor eligibility.
• Ensures that all insurance payments and discounts are applied and any remaining balance is transferred to patient liability, if applicable.
• Takes personal initiative to bring forward process / performance improvements as identified.
• Performs special assigned duties to meet the needs of the department.
• Update patient demographic and insurance information in the patient accounting system.
• Trends are identified and reported to the Supervisor and Manager.
• Attaches supporting documentation to claims. When required verify and update insurance information on the patient’s case(s), to include taking out old payer information, selecting the proper payer number, refreshing and re-triggering the claim, and changing bill dates.
• Properly document steps taken while working account by utilizing the notes screen, to include telephone numbers, changes made to the insurance, and contact names.
• Attends and contributes to departmental meetings. Distributes new and updated information. Provides input and support to overall organization
• Rebill insurance claims by both paper and electronic processes
• Audit accounts for missed payments, adjustments, and remark codes
• Reviews, audits and collects on underpaid or denied insurance claims and stop loss accounts according to insurance carrier contract, guidelines and requirements to ensure proper reimbursement when rebilling a claim.
• Writes and works letters of appeals for all denied or underpaid claims. Works all assigned correspondence and reports within 48 hours of receipt.
• Works with appropriate functional department (Medical Records, Clinics, Business Office) focusing on payer specific CPT & ICD-9 codes for appropriate reimbursement.
• Review denial codes by report in the patient accounting system for accuracy and trends.

Qualifications :

Education :

Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.