PFS Revenue Cycle Representative

Company Description At Lucile Packard Children’s Hospital Stanford, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the‑art facilities, like the newly remodeled Lucile Packard Children’s Hospital Stanford. And it's why we need caring, committed people on our team – like you.

Join us on our mission to heal humanity, one child and family at a time.

The PFS Revenue Cycle Representative is responsible for the timely and accurate processing of patient accounts receivable collections. The specific job duties will be comprised of a combination of responsibilities from among the various areas of PFS operations including Accounts Receivable collections and payer follow‑up, Payer denial review and appeals processing, Customer service, Payment applications, Credit balance review and resolution and Patient advocacy and risk management.

The position is an expert-level position with a superior background in hospital patient accounting and an extensive knowledge of reimbursement requirements of healthcare payers. The PFS Revenue Cycle Representative will act as a key resource for the team management in problem solving difficult issues and analyzing difficult accounts.

• Review and correct all billable claims in billing software in accordance with payor specific guidelines and billing requirements within one working day.
• Work with HIM and applicable departments to resolve questions related to modifiers, orphan CPT/HCPCS codes, charge entry errors, ICD-9 and CPT/HCPCS coding errors, and other questionable claim form elements such as discharge disposition.
• Perform timely and appropriate follow-up to resolve unbillable claims. Using Interpoint, document in account notes all reasons for billing delays and actions taken. Apply the appropriate hold reason code in billing software.
• Process secondary billing in accordance with department procedures.
• Every time an account is accessed, review and correct all account discrepancies, update demographics and other field values such as mnemonic, insurance and billing information, etc., to ensure data integrity in Cerner/Meditech as well as in the billing software.
• Review all high dollar claims for potential stop‑loss criteria and direct stop‑loss claims to correct payor processing unit.
• Prepare and submit appropriate billing attachments as required by specific payors.
• Mail paper claims to appropriate payors.
• Review daily claim rejection reports, resolve rejection issues, and resubmit corrected claims to ACS within 24 hours of rejection.
• Collaborate with manager to resolve claim submission delays exceeding five working days.
• Inform manager of recurring claim errors in order to facilitate system improvements.
• Review and resolve non-covered charges according to facility procedures.
• Review late charge report. Submit late charge or adjustment claims, or write off late charges as appropriate per facility procedures.
• Review assigned Interpoint work lists to ensure appropriate and timely actions are completed.
• Review and respond to mail, correspondence and reports on a daily basis.
• Validate that all charges and/or accounts have been combined in accordance with regulations prior to claim submission.
• Request and submit interim claims on long‑term care inpatients every 30 days.
• Perform timely and appropriate follow‑up on unpaid, underpaid, suspended, and denied accounts.
• Review credit balance accounts and take appropriate action to resolve the credit balance.
• Review remittance advices to ensure payments are correct for services rendered and resolve payment discrepancies.
• Submit adjustment request to reduce account balance for "not medically necessary" (failed) services where an ABN was not obtained.
• Document payment details in patient account notes according to EOB documentation standards.
• Evaluate EOBs and remittance advices by comparing amount paid against the expected reimbursement amount.
• Evaluate denials to determine if appeals are warranted.
• Submit adjustment requests as necessary to…