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JOB SUMMARY
This paragraph summarizes the general nature, level and purpose of the job.
An underpayment specialist identifies and performs follow-up to secure payment on underpaid insurance accounts.
ESSENTIAL FUNCTIONS
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Must perform all duties and responsibilities in accordance with the hospital's policies and procedures, including its Service Standards and its Code of Conduct.
Review referred accounts to validate an underpayment exists.
Analyze expected reimbursement variance reports to identify underpayments on closed carriers.
Submit adjustment requests as needed to correct account balances due to incorrectly applied contractual adjustments.
Input appropriate information into Interpoint, and assign identifying collector code to distinguish underpaid accounts.
Using appropriate format and documentation, request additional payment from insurance company.
Perform timely and appropriate follow-up on all assigned accounts.
Utilize all available tools and resources to perform follow-up in the most efficient manner; electronic transactions, Internet, phone calls, etc.
Escalate unresolved or unreasonably delayed reconsideration requests to insurance company supervisor for special handling.
Review assigned Interpoint work lists to ensure appropriate and timely actions are completed.
Review and respond to mail, correspondence and reports on a daily basis.
Review daily payment reports to identify additional payments on outstanding underpaid accounts. Input appropriate collector code to recognize the underpayment has been resolved and adjust balance accordingly.
Every time an account is accessed, review and correct all account discrepancies, update demographics and other field values such as financial class, insurance and billing information, etc., to ensure data integrity in Meditech and Cerner.
Identify payers with a history of contract violations and collaborate with supervisor to initiate projects to recover underpayments and facilitate future compliance with contract terms.
Produce monthly summary of total identified underpayments and recovered payments.
Evaluate denials to determine if appeals are warranted using appropriate format and documentation, submit non-clinical denial appeals to insurance companies.
Coordinate clinical appeals with case management and other appropriate personnel, and ensure timely filling.
Submit denial adjustments on denied amounts not likely to be paid on appeal, if not billable to a subsequent payor.
Perform timely and appropriate follow-up on all assigned accounts.
Utilize all available tools and resources to perform follow-up in the most efficient manner (electronic transactions, Internet, phone calls, etc.)
Escalate unresolved or unreasonably delayed appeals to insurance company manager for special handling.
Prepare monthly denial logs.
Review assigned Interpoint work lists to ensure appropriate and timely actions are completed.
Identify payers with a history of inappropriate denials and collaborate with manager to initiate projects to prevent future denials.
Follow-up on 50 accounts per day. Follow-up is defined as activity performed that creates account resolution.
MINIMUM QUALIFICATIONS
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Education: High School diploma or GED equivalent.
Experience: Two (2) to five (5) years of progressively responsible and directly related work experience in a healthcare setting
License/Certification: None required.
KNOWLEDGE
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education or licensure/certification.
Ability to follow oral and written instructions and interpret institutional and other policies accurately.
Ability to gather, analyze, and display data in appropriate format and keep accurate records.
Ability to maintain confidentiality of sensitive information.
Ability to perform basic mathematics.
Ability to plan, prioritize and meet deadlines.
Ability to work effectively with individuals at all levels of the organization.
Knowledge insurance and medical terminology.
Knowledge of accounts receivable system like SMS, IDX, or Meditech, Cerner.
Knowledge of computer systems and software used in functional area.
Knowledge of medical reimbursement policies and procedures.
Knowledge of one or more of the following: Medicare, Medi-Cal, Worker's Comp or Managed Care (HMO,PPO,POS, etc).
Knowledge of principles and practices of customer service and telephone courtesy.
PHYSICAL REQUIREMENTS
The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Pay Range
Compensation is based on the level and requirements of the role.
Salary within our ranges may also be determined by your education, experience, knowledge, skills, location, and abilities, as required by the role, as well as internal equity and alignment with market data.
Typically, new team members join at the minimum to mid salary range.
Minimum to Midpoint Range (Hourly): $37.55 to $46.94
Stanford Medicine Children's Health (SMCH) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SMCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.
At Lucile Packard Children’s Hospital Stanford, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.