Able to perform the duties for a PSR II and responsible for the timely and accurate editing, submission, and/or follow-up of assigned claims. Able to process claims for at least two payer types (Commercial, Managed Care, Blue Cross, Medicare, Medicaid, etc.). Assure all assigned claims meet clearinghouse and/or payer processing criteria. Assure appropriate follow-up on assigned work lists. All work meets departmental productivity and quality review standards. Provide Team Management with issues regarding claims follow-up process. Payer response reports and rejection reports are worked timely and meet Departmental Productivity and Quality Review standards. Assure appropriate and timely documentation of all account activity. Correspondence is handled appropriately. WIP counts completed timely. All required reports are filed timely and accurately.


Job Summary:

The Patient Financial Services Representative 3 is responsible for commercial, managed care, and government payer claim submissions in accordance with payer regulations and guidelines. The PFS Representative will facilitate the overall claim process, from resolution of claim edits and payer rejections through the submission of both electronic and paper-based institutional claims.
Essential Functions:

1. Review and resolve claim edits and payer rejections to ensure accurate and timely bill submission to commercial insurance carriers. Adhere to government regulations and commercial payer billing guidelines for compliant billing.
2. Print and submit supplemental billing documentation, including but not limited to claim forms, itemized bills, and/or medical records, as needed.
3. Complete secondary and tertiary billing functions, as applicable, including submission of remittance advices or explanation of benefits forms.
4. Identify, research, and resolve unusual, complex or escalated claim issues. Notify Supervisor of developing trends and propose recommended resolution steps based on impacted payer and dollar amounts.
5. Notate all activities and findings in the billing system and in accordance with established policies and procedures to meet quality assurance and documentation standards.
6. Monitor and complete accounts assigned to PFS Representative through ownership of predetermined workqueues. Notify Supervisor of changes in volumes that may impact daily billing of claims.
7. Establish and maintain a professional and collaborative relationship with payers and Inova staff in order to resolve claim edits and payer rejections. Understand Revenue Cycle responsibilities as they pertain to billing functions and communicate with other Revenue Cycle departments to resolve billing issues.
8. Maintain knowledge of current commercial payers' billing requirements. Communicate new trends and developments to team to ensure accurate and consistent billing practices across the SBO Billing Department.
9. Meet department-specified productivity and quality standards.
10. Perform related duties as required or assigned by SBO Billing Department leadership.

Additional Responsibilities and Requirements:
-Meet established deadlines, prioritize multiple tasks/assignments, and handle constantly changing work environment.
-Adhere to state and federal regulations and Inova Health System policies and procedures pertaining to accurate and compliant billing practices.
-Strong interpersonal communication skills with an ability to work both independently and collaboratively as part of a team.
-Perform other duties as assigned by SBO Billing Department leadership.
-Maintain acceptable levels of attendance and punctuality as outlined in Inova's policies and procedures.
-Maintain confidentiality.