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Retro-Adjudication Representative / Collections representative in Emeryville, CA at Integrated Resources, Inc

Date Posted: 11/8/2018

Job Snapshot

Job Description

  • 2 years insurance billing
  • APeX/EPIC experience preferred
  • Strong Excel/MS Suite (Outlook)
  • good communication - heavy phone/calling
  • customer service

The Medical Group Business Services (MGBS) Department is responsible for the accounts receivable management for the School of Medicine departments (SOM) currently billing through MGBS. MGBS'S primary function is to capture and maximize the billing and reimbursement of the professional fees generated by the SOM.

The Retro-Adjudication Team is responsible for the billing, registration and AR of all governmentand commercial, contract and managed care payers. The unit deals regularly with complex policy and procedural issues that involve regulations with coverage and billing in regards to Medicare, Medi-Cal, CCS, HMO, PPO, and Covered CA payers and the coverage structure for new and existing AR. It is the units' responsibilities to communicate and to coordinate throughout various Client departments, including the Client billing agents to ensure the quality of the university billing process.

Within this unit, the Retro-Adjudication Representatives are responsible for correction of government and commercial, contract and managed care new and existing accounts receivables for MGBS clients. The incumbent demonstrates the ability to perform all aspect of billing and registration with quality. The incumbent's main task is to resolve all registration and difficult coverage issues through constant communication with the payers (by phone or via web access), other MGBS units, Client clinical departments and billing agents and patients/guarantors.

With VFO (Visit Filing Order), it allows MGBS to correct coverage prior to billing. The Retro-Adjudication Representatives are responsible for updating coverage, verification of eligibility and updating visits in PB Charge Review in order to file charges and promote faster payments from the insurance companies.

When resolving the new and existing accounts receivables; the Retro-Adjudication Representative must adhere to the Government rules and regulations and maintain documentation processes to clearly identify to the all of the billing and follow-up staff here at MGBS as well as SBO and clients in regards to the updates and changes made. The Retro-Adjudication Representative must meet minimum productivity standards and quality expectations of their units. The Retro-Adjudication Representative must attend and be engaged in unit and team meetings aimed at increasing knowledge. The incumbent will utilize web based tools, including payor websites and Health Logic prior to calling payors. The incumbent will also conform to all Client, MGBS, government and HIPAA policies and procedures.
of time Essential Function (Yes/No)
Key Responsibilities
(To be completed by Supervisor) 90 yes Retro Review Responsibilities and Duties
  • Corrections of Accounts in Retro-Adjudication WQ and PB Charge Review WQ
  • Examines and evaluates accounts for appropriate registration and coverage.
  • Verification of erred RTE responses in PB Charge Review
  • Assign visits with the correct primary coverage and update unposted charges
  • Timely filing of PB Charge Review charge sessions in keeping with Client lag day goals
  • Correction of registration errors made by frontend and backend staff.
  • Clarification of primary coverage working with the regulations of Medicare and Medi-Cal as well as contractual DOFR set-up.
  • Review of entire AR of account to assure that all billing has been made to the correct payor in the correct order.
  • Interpret account information and enter important details to provide an audit trail for follow up and patient.
  • Research payments received in regards EOB (Explanation of Benefits), APEX and Health Logic to confirm correct primary payment.
  • Review of non-payment and/or incorrect payment for possible registration and coverage. This may include, but is not limited to the use of the following reference tools and guidelines:
    • RTE response
    • Payor Website
    • EOB Information
    • APeX Follow-up Notes and SBO Notes
    • CMS Coverage Guidelines
    • Medi-Cal Eligibility Tool
    • Analyze Explanation of Benefits (EOBs) for accurate posting of rejection, adjustment and other posting requirements needed in APEX.
  • Adheres to the rules and regulations of the different types of payers such as Medicare, Medi-Cal, CCS, PPO, EPO, HMO, Covered CA and commercial insurance.
  • Perform Charge Corrections when cleaning-up charges billed in error.
  • Balancing payments of paid services not posted correctly
  • Retrieve all required information needed in order to evaluate correct credit balance and/or correct refund payee.
  • Effectively communicate with MGBS peers, payers, patients, Client departments Leads, Assistant Managers and managers. .
  • Utilize knowledge of various systems including, but not limited to:
    • Microsoft Word, EXCEL, Outlook, APEX, Payor Web Portals, Health Logic, government and/or non-government websites, and any other information systems which would be required for insurance eligibility, benefit verification or other information needed during detailed follow-up.
    • Perform Special Projects or Other Duties as Assigned by the Manager
    • Attend monthly meetings and unit and team meetings aimed at increasing knowledge.
    • At least 2 years of previous Insurance billing experience.
    • Demonstrate the Ability to communicate effectively (orally and written).
    • Experience with MS EXCEL and OUTLOOK
    • Ability to work independently or as needed with a team.
    • Proven ability to coach and mentor staff for optimal results
    • Demonstrate the ability to perform all aspects of Retro Review with superior quality.
    • Excellent Attendance Record.
    • Problem Solving
    • NA
    • Other Retro-Adjudication Duties May include:
    • Secure guarantor/patient demographic and /or insurance information as required.
    • Process correspondence as required in accordance with departmental procedures.
    • Billing or rebilling corrected claims.
    • Notify manager of possible procedural change for improving efficiency.
5 yes