Patient Account Representative Lead

Job Summary:

Under indirect supervision, trains and directs assigned subordinates. Processes medical claims, insurance reports, and billings for the 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 and obtains background information. Makes arrangements to obtain monies owing and 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 and acts as a Kaiser representative.

Essential Responsibilities:

• 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, and other pertinent documents; verifies completeness and accuracy; ensures efficiency in processing of claims and billings.
• 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; processes insurance claims and reports in compliance with state/federal regulations and Kaiser Health Plan policies.
• Contacts debtor by telephone and/or correspondence; arranges for collection of monies owing; abides by state and federal collection and credit rules and regulations.
• Receives telephone calls and correspondence pertaining to charges and services; researches complaints and inquiries; responds to patients in a timely manner.
• Analyzes history of delinquent accounts; determines whether account is collectible; prepares write-off accounts; submits to supervisor for review.
• Prepares and audits visit records and nurse/doctor notes using various fee schedules; prepares documents with Charge Description Master codes.
• 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; initiates appropriate adjustments.
• Communicates and corresponds effectively with insurance carriers, intermediaries, and members; ensures collectability and maximum reimbursement of revenues.
• Maintains current knowledge of and open communication with state, federal, and community agencies, insurance carriers, and others within Kaiser organization.
• Assists supervisor in developing procedures and documentation.
• Prepares and maintains statistical data on incoming work from various departments; identifies potential operational problems.
• Processes problem claims and bills with ingenuity, initiative, and creativity.
• Documents and records on HPMS computer system all collection action taken on individual accounts.
• Refers difficult problems to supervisor.
• Demonstrates knowledge, skills, and abilities necessary to provide culturally sensitive care and/or service.
• Performs other duties and accepts responsibility as assigned.

Basic Qualifications:

Experience:

• Minimum three (3) years of experience in medical insurance claims processing or related experience.

Education:

• High school diploma; or equivalent combination of education and experience may be considered in lieu of requirements.

License, Certification, Registration:

• N/A

Additional Requirements:

• Demonstrated ability to perform diversified clerical functions and basic accounting procedures.
• Demonstrated familiarity with medical charts and fee schedules.
• Knowledge of medical terminology, CPT-4, and ICD-9-CM coding.
• 10-key by touch.
• Demonstrated knowledge of and skill in adaptability, change management, conflict resolution, creativity, decision making, customer service, interpersonal relations, oral communication, problem solving, project management, teamwork, and written communication.
• Demonstrated knowledge of and skill in word processing, spreadsheet, and database PC applications.
• Knowledge of cost statistics reporting and analysis.
• Knowledge of mainframe collections applications.

Preferred Qualifications:

• Minimum three (3) years of experience in collections in a healthcare industry.
• Associates degree in accounting or related field.