Under the supervision of the Insurance Follow up Supervisor / Manager, this position is responsible for training employees to perform accurate and timely follow up of Commercial and Senior Managed care claims and all payer mix through resolution. Serves as a resource on PM computer systems and Contract specific regulations. Assists with follow up, assists with report analysis and review, and reviews correspondence assuring corrective action is done. Meet and exceed the minimum productivity volume, and standards of work as defined within the departmental policies and procedures, includes billing and follow-up of appropriate billing guidelines, HIPAA rules and regulations, collection and follow-up activities, identification and processing of appropriate claim submission to appropriate Insurance Plan, review/submission of appropriate contractual adjustments, write-offs, credit balances, and correspondence from various Medi-Cal and or Managed Care HMO Plans. Review of Medi-Cal and Managed Care HMO secondary to Primary Medicare and or Commercial Insurances. Using PM software and tools provided to read and interpret specific Managed Care HMO Contracts and or Division of Financial Responsibility (DOFRs), Medi-Cal Managed Care HMO Contracted PPG, and PHP Matrixes to submit bill and or re-submit claims to the appropriate Medi-Cal/Managed Care HMO and commercial insurance plans.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• Computer experience is essential, including, but not limited to: Professional claims Financial Systems, Microsoft Office, Excel and Word processing, Internet applications, Payer websites, with a minimum of 40 wpm typing speed and 10-key by touch. Calculator, fax machine, photocopy machine.
• Ability to perform multiple tasks, good mathematical skills, sound decision-making abilities and good verbal and written communication skills.
• Knowledge and or familiarity of CPT4, HCPCS, ICD10 codes, and medical terminology.
• Experience in follow-up filing of Provider Grievance/Appeals, Claim Inquiry Forms (CIF), PDRs (Provider Resolution Dispute Request) with Medi-cal/ Managed Care HMO and Commercial Insurance Plans to ensure maximum entitled reimbursement.
• Ability to learn new systems, become proficient in development of reports via PM systems and tools provided, proficient in excel and word document for training and QRG’s.
• Familiarity with Commercial third party and Government billing requirements.
• Understanding of Medicare CMS rules and regulations related to accurate claims submission.
• Knowledge of insurance and government billing guidelines and regulations.

Required Experience

Required:

• Minimum 7 years’ experience in Professional Commercial and Government follow up and/or billing

Preferred: ****

• High school graduate
• Two years’ college

• Computer experience is essential, including, but not limited to: Professional claims Financial Systems, Microsoft Office, Excel and Word processing, Internet applications, Payer websites, with a minimum of 40 wpm typing speed and 10-key by touch. Calculator, fax machine, photocopy machine.
• Ability to perform multiple tasks, good mathematical skills, sound decision-making abilities and good verbal and written communication skills.
• Knowledge and or familiarity of CPT4, HCPCS, ICD10 codes, and medical terminology.
• Experience in follow-up filing of Provider Grievance/Appeals, Claim Inquiry Forms (CIF), PDRs (Provider Resolution Dispute Request) with Medi-cal/ Managed Care HMO and Commercial Insurance Plans to ensure maximum entitled reimbursement.
• Ability to learn new systems, become proficient in development of reports via PM systems and tools provided, proficient in excel and word document for training and QRG’s.
• Familiarity with Commercial third party and Government billing requirements.
• Understanding of Medicare CMS rules and regulations related to accurate claims submission.
• Knowledge of insurance and government billing guidelines and regulations.