Patient Account Representative Lead

Job Summary

Under indirect supervision, trains and directs assigned subordinates; processes medical claims, insurance reports, billings for purpose of billing non-dues revenue guaranteed by third party payors and patients; performs diversified clerical functions and basic accounting procedures; edits and retrieves accounting data related to claims, insurance payments, suspense and cost logs; assumes complete responsibility for assigned accounts; obtains background information; makes arrangements to obtain monies owing;

performs other collection responsibilities as needed; abides by state collection and credit regulations; interprets and complies with state/federal regulations, laws and guidelines in reference to third party payors; acts as liaison between assigned subordinates and management; maintains current knowledge of Kaiser Health Plan benefits and policies; acts as Kaiser representative.

• Plans, coordinates, delegates, and schedules work; orients and trains assigned subordinates.
• Receives, reviews, and controls requests for medical information, visit records, nurse/doctor notes, coordination of benefits, Medicare Secondary Payor screening forms and other pertinent documents; verifies completeness and accuracy; ensures efficiency in processing of claims and billings; obtains medical charts and all other data pertaining to request/claim.
• Verifies patient/member eligibility, benefits and coverage with Kaiser Health Plan, Medicare, Medicaid, and other carriers to determine primary payor.
• Audits, abstracts, and summarizes pertinent data from patient medical records, nurse/doctor notes and other documents; processes insurance claims and reports in compliance with state/federal regulations, laws, guidelines and Kaiser Health Plan policies; obtains physician signature and/or signs as provider representative; prepares service charge letters and invoices referring to fee schedule.
• Contacts debtor by telephone and/or correspondence; arranges for collection of monies owing; abides by state and federal collection and credit rules and regulations; schedules interviews with debtors.
• Receives telephone calls and correspondence pertaining to charges and services; researches complaints and inquiries; responds to patients in timely manner; maintains positive customer relationships through effective communications and follow-up.
• Analyzes history of delinquent accounts; determines whether account is collectible; prepares write‑off accounts; attaches pertinent information to assist outside attorney; submits to supervisor for review; summarizes monthly write‑off report (e.g. breakdown of amounts, service locations, date of service, H.P./N.P. and overall reason for assignment to collection agency).
• Prepares and audits visit records and nurse/doctor notes using various fee schedules; prepares documents (e.g. charges, payments, adjustments) with Charge Description Master codes, required billing coding conventions, and batch totals.
• Assists with identification and preparation of Medicare and Medicaid payments and contractual adjustments for data entry.
• Prepares and maintains ledger/log of payments received and suspended payments; reconciles to subledger and cost report logs.
• Researches rejected or unpaid claims using aging reports; resubmits claims or inquiries; reviews adjustments; determines validity; initiates appropriate adjustments.
• Researches and resubmits rejected claims for payment; researches and resolves unmatched visit records and claims.
• Communicates and corresponds effectively with insurance carriers, intermediaries, members, in-service orientation to other departments/personnel; obtains complete and valid information; ensures collectability and maximum reimbursement of revenues.
• Maintains current knowledge of and open communication with state, federal and community agencies, insurance carriers, intermediaries and others within Kaiser organization; ensures proper and adequate exchange/interpretation of data and information; ensures maximization of payments.
• Assists supervisor in developing procedures and documentation.
• Prepares and maintains statistical data on incoming work from various…