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AIM OF THE POSITION

The Patient Advocate Representative follows-up on the status of submitted claims and invoices; requests medical records as needed; prepares various medical appeals and the submissions of such appeals to insurance carriers; follows-up on all submitted medical appeals in a timely manner.

POSITION WITHIN THE ORGANIZATION

1. Reports to Reimbursement Supervisor

2. Cooperates with all departments across the organization

3. Organizes activities with Customer Care, Sales, Commercial and external vendors

4. Participates in:

– Department meetings

– Project meetings

– Working groups

– Project groups

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Collects money due from insurance companies, hospital and patients in compliance with CLIA, OIG and all other applicable legal requirements.

• Contacts insurance companies to follow up on claims and appeals which have been submitted, but no payment or correspondence received within the allotted time frame.

• Processes and follows up with patients for copays and deductible amounts due.

• Contacts clients to obtain medical records as needed for submission of a medical appeal or

payer’s review of a claim.

• Prepares custom appeal letters and letters of interest to various insurance carriers and managed care groups.

• Reviews files to determine if amounts should be written off based on acceptable reimbursement, then forwards these to the Reimbursement Manager.

• Investigates and prepares any necessary refund requests from payors for submission to the Reimbursement Manager.

• Negotiates reimbursement single settlements with various insurance carriers and third party administrators, based upon department guidelines.

• Interfaces with insurance company representatives, doctor’s offices and hospitals regarding schedule of services and billing inquiries.

• Assists department director in the development of new procedures and systems to enhance productivity.

• Provides account information to the sales force as needed.

The above listing represents the general duties considered essential functions of the job and is not to be considered a detailed description of all the work requirements that may be inherent in the position.

KEY CONTACTS

Internal

o This position may interface with all departments within the company.

External

o External Vendors

EDUCATION AND EXPERIENCE REQUIREMENTS

EDUCATION

• High school diploma or general education degree

EXPERIENCE

· 3+ years related experience

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S)

Specific Knowledge Required:

Knowledge: Comprehension of a body of information acquired by experience or study.

Skill: A present, observable competence to perform a learned activity.

Ability: Competence to perform an observable behavior.

• Advanced technical knowledge of Microsoft products required (Excel, Word, Outlook)

• Must be able to work in a fast-paced environment

• Must have strong organizational skills and attention to detail

• High degree of accuracy

• Manage multiple tasks independently

• Other skills necessary are accounting, data entry, general math, analytical, thoroughness, research, verbal/written communication

BEHAVIOURAL COMPETENCIES/DESIRED SKILLS

• Excellent problem resolution

• Excellent customer service skills

• Outside-the-box thinker

· PRIVACY NOTICE: To review the California privacy notice, click here:

· Employees must not be classified as an excluded individual who is prohibited from participation in any Federal health care program.

WORKING ENVIRONMENT

Establishes ADA (Americans with Disabilities Act) requirements

ENVIRONMENT/SAFETY/WORK CONDITIONS

Working conditions (inside or outside the office).

• General office environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Maintains a clean, neat, and orderly work area.

• Adheres to Department Specific Safety Guidelines.

• Standing, sitting, walking, bending, reaching, manual manipulation, and lifting up to 15 pounds.

TRAVEL

· No travel is required

OTHER DUTIES

Other duties as required by management.