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Required Skills

• Review medical records and accurately code the principal and all secondary diagnoses and procedures using ICD-9-CM, ICD-10-CM, and/or CPT coding conventions; sequence the diagnoses and procedures using coding guidelines; abstract and compile data from medical records to assign the most appropriate codes for optimal reimbursement.
• Coding of Outpatient Diagnostic Accounts- as assigned performs coding analysis on all outpatient diagnostic accounts utilizing 3M and/or other coding products. Abstracts all coded accounts in coding system per procedure.  Ensure an APC assignment is accurate.
• Participates in required continuing education and compliance training programs to maintain an understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques to support the effective application of ICD-9-CM, ICD-10-CM and CPT coding guidelines to outpatient diagnoses and procedures. Staff will maintain up-to-date knowledge of medical records practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Centers for Medicare and Medicaid (CMS), Federal Intermediary (FI) and other related organizations. 
• Ensures compliance with all current Memorial Medical Center and department policies and procedures.
• Embodies the Memorial Health Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:
• Demonstrates ability to cooperate with Memorial Medical Center management personnel, physicians and other persons contacted during the working day.
• Enter and retrieve patient medical data from computer terminal updating entries as necessary; audit medical record for accuracy and completeness, note deficiencies and refer for appropriate follow up and completion.
• Participates in monthly coding meeting with Coding Supervisors and other meetings at determined appropriate.
• Serve as a member of designated divisional committees and other steering committees as appropriate.
• Promotes MHS Guest Relations philosophy, Statement of Values, and follows MHS Behavior Standards and Code of Conduct.
• Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.

Required Skills

1. Maintain working knowledge and understanding of CPT’s and HCPS codes that relate to Medical Imaging procedures and supplies.

1. Manages the creation, deletion, and edits on all Imaging CPT / HCPC codes set forth by the AMA and Medicare carrier for this region. Stays current with all regulation changes and understands how those changes impact the codes.

1. Works closely with Finance and IT in order to update Imaging CPT/HCPC and charge master billing codes within the hospital systems due to regulatory changes.

1. Provides assistance in building new imaging charge codes and the related components to ensure compliance with regulations and reimbursement.

1. Reviews daily Imaging patient charges that interface with the hospital billing system to ensure documentation and appropriateness.

1. Educate staff on changes to imaging charge codes to ensure accurate use.

1. Analyze, discuss and resolve any Imaging report documentation discrepancies with imaging physicians.

1. Maintains a working knowledge and understanding of local and national coverage decisions (LCD/NCD) that relate to Medical Imaging.

1. Maintain working knowledge and understanding of the Medical Imaging Information system (RIS) and hospital billing systems.

1. Participates in required continuing education and compliance training programs to maintain an understanding of disease processes and Interventional Radiology surgical techniques to support effective application of ICD and CPT coding guidelines for outpatient imaging procedures.

1. Thorough understanding of medical terminology and human anatomy.

1. Promotes MHS guest relations philosophy, Statement of Values and follows MHS Behavior Standards and Code of Conduct.

1. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.

Required Skills

• Receives and examines daily reports, for assigned billing transactions, and determines which require further analysis and action. Investigates those claims with incomplete/incorrect information and resolves problems or errors to ensure complete and applicable information accompanies the claim.

• Prioritizes billings and claims information and prepares the necessary paperwork, ensuring careful adherence to insurers’ guidelines (where applicable), timeliness, accuracy, and processing procedures. At prescribed intervals, follows up for review to ensure smooth processing and timely delivery of monetary reimbursements.

• Analyzes ECS (Electronic Claims Submissions) reports containing rejected account information and performs the necessary research to resolve the reason(s) for the rejection and secures any other required information.

• Investigates unpaid invoices, claim denials, and insurance correspondence to develop response or appeals to facilitate claim resolution. Contacts patients, guarantors, or other sources of third party payment as necessary to secure arrangements for payment.

• Researches and resolves complex issues associated with billing and collection of patient accounts. As applicable, identifies, documents, and reports problematic trends to management.

• Communicates and resolves claims issues with a variety of internal and external sources. This may include internal departments, patients (or other responsible parties), third-party payors, social service agencies, Medicare/Medicaid staff, other insurance carriers, service providers, and collection agencies.

• Communicates with patients, via phone or mail, to request information/documentation related to claim resolution, or to respond to patient inquiries or correspondence, or to facilitate payment of outstanding balances. Meets with customers in person as requested.

• Initiates adjustments to accounts receivables, including contractuals / allowances, within scope of expertise and authority granted. Log sheet is completed for any claim above permission levels, and supporting detail information and related documentation is attached and forwarded to the Reimbursement Manager for approval.

• Enters account notes in online systems and electronic files to ensure accurate documentation regarding the status of billings, claims, payments, collections activities, refunds and adjustments.

• Ensures compliance to Memorial Home Services of Central Illinois, Inc. policies, by identifying, initiating and processing accurate and timely refunds to private payers, commercial insurance, and/or governmental entities, any time an overpayment is identified.

• Responds to requests from internal departments regarding the proper coding, billing, and processing of claims.

• As directed and defined by management, orients and cross-trains on other unit duties that are outside of regularly assigned area of responsibility. May serve as a back up for other areas within the unit or department, especially during times of special needs or staff absences.

• Assists with training of new Reimbursement and Customer Service staff.

• Performs both Collections and Denial functions when necessary.

• Participates on work teams for Quality Improvement when necessary.

• Analyze receivable reports and follow-up on a timely basis the status of unpaid claims.

• Communicate professionally with hospitals, physician offices, co-workers and customers as appropriate.

• Monitor On-Hold aging claims to resolve issues/problems and facilitate timely release in accordance with department standards.

• Performs other related work as required or requested.

Required Skills

1. Accesses external insurance providers’ websites to determine and/or verify patients’ insurance eligibility and account status.

1. Receives and examines daily listings for all denominations and types of patient accounts and determines which require further analysis and action.

1. Investigates assigned patient accounts with incomplete/incorrect information and resolves problems or errors to ensure complete and compliant information accompanies the claim.

1. Follows up and investigates all denominations and types of unpaid items and other issues associated with unpaid claims. Contacts patients, guarantors, or other sources of third party payment and secures arrangements for prompt payment.

1. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:

• SAFETY: Prevent Harm – I put safety first in everything I do.  I take action to ensure the safety of others.
• COURTESY: Serve Others – I treat others with dignity and respect.  I project a professional image and positive attitude.
• QUALITY: Improve Outcomes – I continually advance my knowledge, skills and performance.  I work with others to achieve superior results.
• EFFICIENCY: Reduce Waste – I use time and resources wisely.  I prevent defects and delays.

1. Receives and researches insurance claim denials, rejections and underpayments, and as necessary, prepares the necessary paperwork to appeal the denial.

1. Reviews correspondence relating to payments and claims; conducts the necessary research to provide supplementary background information regarding the inquiry

1. Researches and resolves complex issues associated with patient insurance accounts. As applicable, identifies, documents, and reports problematic trends to management.

1. Analyzes reports containing rejected account information and performs the necessary research to resolve the reason(s) for the rejection and secures any other required information.

1. Provides input regarding system edits designed to identify and ensure consistent and compliant data necessary for processing medical insurance claims.

1. Responds to requests from internal departments regarding the proper coding, billing, and processing of medical insurance claims.

1. Communicates and resolves issues with a variety of internal and external sources to resolves issues involving medical insurance claims. This may include internal departments, patients (or other responsible parties), third-party payors, social service agencies, Medicare/Medicaid staff, other insurance carriers, service providers, and collection agencies.

1. Initiates corrections to all denominations and types of charges and contractual/allowances within scope of expertise and authority granted.

1. Identifies and calculates write-off amounts and secures the necessary approvals from management for processing.

1. Documents online systems and electronic files to ensure accurate data is noted regarding the status of claims and payments.

1. Researches complex issues on all denominations and types of accounts and coordinates their resolution in a timely manner.

1. Ensures compliance to managed care contract guidelines and processes at each work step to facilitate accurate and timely reimbursements to the organization.
2. May assist with special projects, analyses, or audits.

1. As directed and defined by management, orients and cross-trains on other unit duties which are outside of regularly assigned area of responsibility. May serve as a back-up for other areas within the unit or department, especially during times of special needs or staff absences.

1. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.

Required Skills

• Customer Assistance:
  Assist patients and others with account issues by explaining and coordinating resolutions for billing, private pay options, collection efforts, coordination of benefits, and insurance coverage. Serve as a liaison between external resources and patients.

• Negotiation and Payment Collection:
  Negotiate with patients and families to explain, collect, and record payments and deposits using electronic payment systems. Process cash, checks, and credit card transactions as appropriate, ensuring the accuracy and security of the cash drawer and all cash equivalents.

• Cash Reconciliation:
  Reconcile cash accounts and resolve discrepancies. Prepare bank deposits for pickup and pursue account balances and payments in alignment with Patient Financial Services policies to maximize reimbursement.

• Relationship Building:
  Build strong working relationships with assigned business units, hospital departments, and provider offices. Identify trends in payment issues and communicate effectively with internal and external customers to educate and resolve problems.

• Complex Issue Resolution:
  Research and resolve complex issues related to patient accounts. Document and report problematic trends to management while collaborating with the patient financial services team to reduce outstanding accounts receivable balances.

• Account Management:
  Review and consolidate multiple accounts for individual patients. Explain available payment options and establish appropriate payment plans according to departmental policies and procedures.

• Documentation:
  Accurately record all customer visits to the Lobby Office, ensuring proactive discussion of all patient accounts. Log and batch accounts according to established procedures.

• Collection Activity Reporting:
  Thoroughly document all collection activities performed and complete/send daily account payment reconciliation reports to the appropriate teams within the Springfield Memorial Hospital Finance Department.

• Coordination:
  Coordinate with Springfield Memorial Hospital Patient Financial Services, Utilization Management, physicians, and medical offices to ensure consistent financial documentation and a cohesive approach to patient and organizational needs.

• Account Prioritization:
  Identify, prioritize, and resolve problematic accounts, verifying patient eligibility for potential payer sources and financial assistance.

• Benefit Eligibility Analysis:
  Analyze reports from various hospital sources to resolve benefit eligibility concerns and determine suitability for financial assistance. Initiate coverage acquisition as appropriate.

• Training and Cross-Training:
  Orient and cross-train others within the assigned area as directed by management. Understand the functionality of all related computer systems and assist other areas during times of need.

• Interpersonal Skills:
  Demonstrate superior patient relations and interpersonal skills, maintaining a calm and even temperament when interacting with staff, patients, and the public. Promote a positive work environment and contribute to the overall team efforts.

• Additional Duties:
  Perform other related duties as required or requested.

Required Skills

• Completes all steps of pre-registration/registration; verifies patient identity and demographic information through appropriate tools. Identifies/captures appropriate health insurance benefit eligibility based on contract/regulatory differentiation. Facilitates appropriate billing of claims and hospital reimbursement. Obtains and validates proper consent for patient treatment.
• Schedules patients for Mammography procedures efficiently, effectively, and according to established protocol for modality, location, facility capabilities, insurance requirements, type of exam, patient preferences, and urgency.
• Educates patients/others regarding the resolution of billing, private pay options, collection efforts, coordination of benefits, third party and governmental payment criteria, insurance coverage, payments, and denials. May serve as a liaison between external resources and patients on issues requiring SMH involvement.
• Coordinates with SMH Patient Financial Services, Utilization Management, physicians, and medical offices to ensure consistent financial documentation across the enterprise, and an interdisciplinary approach to patient and organizational needs.
• Adheres to all CMS Conditions of Participation regulations and Section 1154(e) of the Social Security Act regarding delivery, explanation, and acquisition of patient/designated representative signatures.
• Verifies medical necessity, and obtains appropriate signature on Advance Beneficiary Notice of non-coverage (ABN) per CMS regulations at points of patient access.
• Negotiates with patients and families to collect patient co-pays and/or deposits at point of service. Supports Patient Access Services POS (Point of Service) collection goals as defined by Revenue Cycle leadership and best practice benchmarks.
• Triages, documents, and initiates referrals of patients to Medicaid vendor and/or for financial assistance, per the Illinois Fair Patient Billing Act, Illinois Uninsured Patient Discount Act, and established SMH procedures.
• Identifies/reviews services requiring pre-authorization/pre-certification by Medicare, Medicaid, Commercial, and Managed Care payers, to ensure provider eligibility requirements are met prior to receiving service. Utilizes appropriate technology and/or communicates with physician offices.
• Analyzes reports containing rejected accounts from a variety of hospital sources, including Non-Patient Access registration departments, and resolves toward verification of patient benefit eligibility, and subsequent reimbursement from all possible payer sources, or determines suitability for financial assistance.
• Orients and cross-trains others within assigned area of responsibility as directed and defined by management. May assist other areas within the unit or department, as necessary, during times of special needs or staff absences. May be required to work night or weekend shifts.
• Ensures compliance with all applicable HIPAA, Joint Commission, CDC, SMH, and state and federal statues, providing required associated literature to patients at all PAS access points. Educates patients regarding Advance Directives, Medicare D prescription coverage, SMH, Joint Commission, and Illinois Department of Public Health grievance process as appropriate.
• Maintains current knowledge of, and complies with, the Illinois Fair Patient Billing Act and Illinois Uninsured Patient Discount Act at all times.
• Completes Illinois DHS legal forms for psychiatric admits, in compliance with State of Illinois and SMH statues and guidelines. Provides relevant patient/family education.
• May rotate work settings, i.e., patient registration, bedside registration, or other SMH campus environments. May be required to provide coverage for the SMH Financial Lobby Office.
• Develops and maintains a comprehensive knowledge of the health system organization and its functions. Completes all assigned annual organizational education
• Meets expectations for productivity, accuracy, and point of service collections
• Attendance at quarterly department meetings is mandatory unless absence is approved by PAS management prior to the meeting date.
• Performs pre-registration functions as requested.
• Performs other related work as required or requested.

Required Skills

• Completes all steps of pre-registration/registration; verifies patient identity and demographic information through appropriate tools. Identifies/captures appropriate health insurance benefit eligibility based on contract/regulatory differentiation. Facilitates appropriate billing of claims and hospital reimbursement. Obtains and validates proper consent for patient treatment.
• Schedules patients for Mammography procedures efficiently, effectively, and according to established protocol for modality, location, facility capabilities, insurance requirements, type of exam, patient preferences, and urgency.
• Educates patients/others regarding the resolution of billing, private pay options, collection efforts, coordination of benefits, third party and governmental payment criteria, insurance coverage, payments, and denials. May serve as a liaison between external resources and patients on issues requiring SMH involvement.
• Coordinates with SMH Patient Financial Services, Utilization Management, physicians, and medical offices to ensure consistent financial documentation across the enterprise, and an interdisciplinary approach to patient and organizational needs.
• Adheres to all CMS Conditions of Participation regulations and Section 1154(e) of the Social Security Act regarding delivery, explanation, and acquisition of patient/designated representative signatures.
• Verifies medical necessity, and obtains appropriate signature on Advance Beneficiary Notice of non-coverage (ABN) per CMS regulations at points of patient access.
• Negotiates with patients and families to collect patient co-pays and/or deposits at point of service. Supports Patient Access Services POS (Point of Service) collection goals as defined by Revenue Cycle leadership and best practice benchmarks.
• Triages, documents, and initiates referrals of patients to Medicaid vendor and/or for financial assistance, per the Illinois Fair Patient Billing Act, Illinois Uninsured Patient Discount Act, and established SMH procedures.
• Identifies/reviews services requiring pre-authorization/pre-certification by Medicare, Medicaid, Commercial, and Managed Care payers, to ensure provider eligibility requirements are met prior to receiving service. Utilizes appropriate technology and/or communicates with physician offices.
• Analyzes reports containing rejected accounts from a variety of hospital sources, including Non-Patient Access registration departments, and resolves toward verification of patient benefit eligibility, and subsequent reimbursement from all possible payer sources, or determines suitability for financial assistance.
• Orients and cross-trains others within assigned area of responsibility as directed and defined by management. May assist other areas within the unit or department, as necessary, during times of special needs or staff absences. May be required to work night or weekend shifts.
• Ensures compliance with all applicable HIPAA, Joint Commission, CDC, SMH, and state and federal statues, providing required associated literature to patients at all PAS access points. Educates patients regarding Advance Directives, Medicare D prescription coverage, SMH, Joint Commission, and Illinois Department of Public Health grievance process as appropriate.
• Maintains current knowledge of, and complies with, the Illinois Fair Patient Billing Act and Illinois Uninsured Patient Discount Act at all times.
• Completes Illinois DHS legal forms for psychiatric admits, in compliance with State of Illinois and SMH statues and guidelines. Provides relevant patient/family education.
• May rotate work settings, i.e., patient registration, bedside registration, or other SMH campus environments. May be required to provide coverage for the SMH Financial Lobby Office.
• Develops and maintains a comprehensive knowledge of the health system organization and its functions. Completes all assigned annual organizational education
• Meets expectations for productivity, accuracy, and point of service collections
• Attendance at quarterly department meetings is mandatory unless absence is approved by PAS management prior to the meeting date.
• Performs pre-registration functions as requested.
• Performs other related work as required or requested.

Required Skills

• Pre-Registration/Registration: Completes all steps of pre-registration/registration, verifies patient identity and demographic information, and captures health insurance benefit eligibility based on contract/regulatory requirements. Ensures proper consent for patient treatment is obtained.

• Mammography Scheduling: Schedules patients for Mammography procedures according to established protocols, ensuring proper modality, location, insurance requirements, patient preferences, and urgency.

• Billing and Payment Education: Educates patients on billing resolution, private pay options, collection efforts, coordination of benefits, third-party payments, insurance coverage, payments, and denials. Acts as a liaison between external resources and patients for issues requiring SMH involvement.

• Coordination of Financial Documentation: Works with Patient Financial Services, Utilization Management, physicians, and medical offices to maintain consistent financial documentation and interdisciplinary collaboration.

• Regulatory Compliance: Adheres to CMS Conditions of Participation and Section 1154(e) of the Social Security Act, ensuring proper patient signature acquisition. Verifies medical necessity and obtains signatures on Advance Beneficiary Notice of non-coverage (ABN) per CMS regulations.

• Co-Pay and Deposit Collection: Negotiates with patients and families to collect co-pays and/or deposits at the point of service, supporting POS collection goals.

• Financial Assistance Referrals: Triage, document, and refer patients to Medicaid vendors or financial assistance per the Illinois Fair Patient Billing Act and SMH procedures.

• Pre-Authorization/Pre-Certification: Identifies services requiring pre-authorization and works with physicians to meet eligibility requirements prior to service.

• Account Rejection Resolution: Analyzes and resolves rejected accounts from various hospital sources, ensuring verification of patient benefit eligibility and reimbursement from all payer sources, or suitability for financial assistance.

• Staff Training and Coverage: Orients and cross-trains others within the department and provides coverage during staff absences or special needs.

• HIPAA and Regulatory Compliance: Ensures compliance with all HIPAA, Joint Commission, CDC, SMH, and state and federal regulations. Educates patients about Advance Directives, Medicare D coverage, and the grievance process as appropriate.

• Knowledge Maintenance: Maintains up-to-date knowledge of applicable regulations, including the Illinois Fair Patient Billing Act and Illinois Uninsured Patient Discount Act, and completes all required annual organizational education.

• Legal Forms Compliance: Completes Illinois DHS legal forms for psychiatric admits in compliance with state and hospital policies, providing relevant education to patients and families.

• Flexible Work Settings: May rotate between different work settings such as patient registration, bedside registration, or SMH campus environments, and provide coverage for the SMH Financial Lobby Office.

• Productivity and Accuracy: Meets expectations for productivity, accuracy, and point of service collections. Attends quarterly department meetings unless otherwise approved.

• Additional Duties: Performs other related work as assigned.

Required Skills

• Insures the accuracy and validity of the demographic and insurance information.

• Post insurance and/or personal payments as well as adjustments as directed and indicated on EOB’s, balancing input amounts against the control totals for the individual accounts upon completion of entry.

• Processes and complete daily deposits prior to 2:00 pm daily.

• Review and process all health insurance claims received daily.

• Provide insurance forms to patients when requested.

• Researches unpaid Insurance claims and follow-up for reasons of non-payment.

• Establish payment arrangements in line with the guidelines established.

• Respond to patient inquires made by telephone or in writing.

• Review credit balances on accounts and take appropriate action including initiating refunds, correcting adjustments or transferring balance to correct account.

• Research and correct edits or errors in claim scrubber system.

• Respond to Client inquiries concerning accounts via telephone or e-mail.

• Demonstrate a professional behavior and provide Excellent Customer Service at all times.

• Performs other duties as assigned.