Pathway Healthcare is a leading behavioral health organization dedicated to providing comprehensive care for individuals facing mental health challenges, and substance abuse issues. We believe in a holistic approach to treatment, addressing both physical and mental well-being to foster lasting recovery and wellness.

We value our team members and want our team members to experience a positive culture where they feel valued. Our team members have access to health benefits, including Teladoc that is free to all full-time employees, as well as PTO, and paid holidays. If you are passionate about helping people and want to be part of a team where you will be valued and have the opportunity to grow, then send us your resume!

POSITION OVERVIEW

This position is responsible for key revenue cycle generation processes that have an impact on the company’s cash flow including, but not limited to establishing hard-copy and electronic claims submission, entering third party billing information and subsequent medical billings and ensuring all documentation is present and claims are billed in a timely manner and without error.

ROLE RESPONSIBILITIES

• Applies a thorough understanding / interpretation of Explanation of Benefits (EOBs) and remittance advices, including when and how to ensure that correct and appropriate payment and adjustment has been applied.
• 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.
• Resubmits claims with necessary information and making sure that all requirements of corrected claims are met.
• Anticipates potential areas of concern within the follow-up function; identify issues and trends.
• Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.
• Resolves work queues according to the prescribed priority and / or per the direction of management and in accordance with policies, procedures and other job aides.
• Assists with unusual, complex or escalated issues as necessary.
• Organizes open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an on-line payer portal, etc.
• Accurately documents patient accounts of all actions taken in billing system.
• Identifies potential trends in denials / reimbursement by payer or by type, denial reason, or coding issue and reports to supervisory staff for appropriate escalation.
• Keeps management informed of changes in billing requirements and rejection or denial codes as they pertain to claim processing and coding.
• Communicates with supervisor and staff regarding insurance carrier contractual and regulatory requirements that impact payment and denials.
• 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 denial resolution in accordance with organizational policies and procedures.
• Maintains current knowledge of internal, industry, and government regulations as applicable to assigned function.
• Understands detailed billing requirements, denial reason codes, and insurance follow-up practices.

QUALIFICATIONS & EDUCATION REQUIREMENTS

• This position requires frequent to extensive contact with individuals both inside and outside the company. Due to the nature of the contacts (including phone calls to insurance companies, Medicaid offices, Medicare regions and families with insurance payments) this position requires extreme tact.
• Possesses the ability to work in a constantly changing environment, good judgment skills, and capable of making decisions with attention to detail.
• Must have excellent organizational skills and ability to prioritize and coordinate workload with high degree of proficiency and accuracy.
• Must have excellent problem-solving skills.
• Ability to work easily and cooperatively with other departments.
• Ability to work independently and follow through on tasks.
• Ability to work well under pressure in a flexible, diplomatic and expeditious manner.
• Maintains strict confidentiality of patients’ medical records and adherence to all HIPAA and PWHC policies and regulations.
• Excellent and accurate computer skills. Including the ability to use, Microsoft Excel, Microsoft Word, E-Mail.
• Good overall knowledge of RCM departments and their functions.
• High School Diploma.
• Completion of an Associates degree or certificate program in a related field preferred.