The Government Collector/Appeals Specialist will manage patient accounts from the point of discharge through billing edits to contract management account net down to final collection of the expected contract amount. Possess and maintain governmental payer knowledgeable of all billing standards and collection requirements. Acts as a collector and perform necessary follow-up to obtain the appropriately owed reimbursement for hospital services. Responsible for all accounts with a contracted insurance as the primary or current payer. Collector will using work lists follow-up with governmental payers to liquidate inventory submitted.

Essential Duties:

• In-depth technical knowledge of billing and collections guidelines for Medicare, Medi-Cal, local Medi-Cal entities. Continually keeping abreast of billing changes and requirements to ensure prompt defect free claims for timely payment to minimize denials.
• Must have significant knowledge of Medi-Cal TAR/SARs approval processes and required follow-up. Must possess written skills to address TAR deferrals and be self-sufficient in developing written appeals to overturn denials. Interface with Medi-Cal Field Offices to affect claim payments.
• Perform all necessary functions to appropriately submit claims for payment. Work independently on inventory for account follow-up appeals and identify accounts that need escalation to ensure we liquidate inventory.
• Identify opportunities for improvement and, when appropriate, develop and implement effective solutions.
• Actively contacts payers by phone, mail or websites including DDE, Common Working File and other State entities to identify barriers impact payment of claims. Work independently to address barriers to allow claims to be paid..
• Handles all customer calls and payer inquiries accurately regarding charge inquiries, account status, etc. Interface with patients with regards to missing or lacking information necessary for governmental payer to pay claims.
• Processes correspondence within the established timeline of 5 days from receipt. Work EOBs and remits within two work days, Identify patient liability and process accordingly.
• Resolves credit balance accounts in a timely manner. Resolves any underpayment or denial with appropriate action to ensure all accounts are paid per contracted rate.
• Knowledge of all contract payers, rates and agreements. Ensures accurate insurance coding is utilized.
• Properly evaluates reimbursement amounts to ensure maximum payment is being received for all services provided. Appeals when underpayments are received.
• Places calls to health plan or looks on insurance contracts website to obtain patient eligibility information, updates insurance and/or forwards claim to medical group to update.
• Has a clear understanding of the payer matrix of financial responsibility and utilizes this knowledge to do appropriate follow-up on accounts.
• Enters appropriate documentation online to records activity on patient accounts including expected reimbursement amounts when calculated manually.
• Uses initiative to resolve problems with appropriate action and follow-through, including documentation when involved in patient/department issues.
• Identifies existing problems in the workflow and utilizes resources available to maintain a productive workflow.
• Accommodates to changes in workload within the department by assisting others.
• Keeps supervisor informed when problems may interfere with work being completed on time.
• Adapts to changes of unusual circumstances, promotes cooperation and minimizes disruption to working environment.
• Participates in review, revising and developing policies and procedures for the department.
• Performs other duties as assigned.

Required Qualifications:

• Req High school or equivalent
• Req Bachelor's degree Degree in a related field

• OR equivalent in years of service within the scope of AR Management

• Req 3 years Acute care hospital collections and follow-up experience.

• Req Working knowledge of governmental regulations and requirements.
• Req Excellent written skills for appeals purposes.
• Req Knowledge of medical terminology and coding.
• Req Demonstrate excellent customer service behavior.
• Req Demonstrates excellent verbal and written communication skills.

Preferred Qualifications:

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)