Patient Account Representative Lead; Full-time, WILI PA

Under indirect supervision, trains and directs assigned subordinates; processes medical claims, insurance reports, billings for purpose of billing non-dues revenue guaranteed by third party payors and patients; performs diversified clerical functions and basic accounting procedures; edits and retrieves accounting data related to claims, insurance payments, suspense and cost logs; assumes complete responsibility for assigned accounts; obtains background information; makes arrangements to obtain monies owing; performs other collection responsibilities as needed; abides by state collection and credit regulations; interprets and complies with state/federal regulations, laws and guidelines in reference to third party payors; acts as liaison between assigned subordinates and management; maintains current knowledge of Kaiser Health Plan benefits and policies; acts as Kaiser representative.

• Plans, coordinates, delegates, and schedules work; orients and trains assigned subordinates.


• Receives, reviews, and controls requests for medical information, visit records, nurse/doctor notes, coordination of benefits, Medicare Secondary Payor screening forms and other pertinent documents; verifies completeness and accuracy; ensures efficiency in processing of claims and billings; obtains medical charts and all other data pertaining to request/claim.


• Verifies patient/member eligibility, benefits and coverage with Kaiser Health Plan, Medicare, Medicaid, and other carriers to determine primary payor.


• Audits, abstracts, and summarizes pertinent data from patient medical records, nurse/doctor notes and other documents; processes insurance claims and reports in compliance with state/federal regulations, laws, guidelines and Kaiser Health Plan policies; obtains physician signature and/or signs as provider representative; prepares service charge letters and invoices referring to fee schedule.


• Contacts debtor by telephone and/or correspondence; arranges for collection of monies owing; abides by state and federal collection and credit rules and regulations; schedules interviews with debtors.


• Receives telephone calls and correspondence pertaining to charges and services; researches complaints and inquiries; responds to patients in timely manner; maintains positive customer relationships through effective communications and follow-up.


• Analyzes history of delinquent accounts; determines whether account is collectible; prepares write-off accounts; attaches pertinent information to assist outside attorney; submits to supervisor for review; summarizes monthly write-off report (e.g. breakdown of amounts, service locations, date of service, H.P./N.P. and over-all reason for assignment to collection agency).


• Prepares and audits visit records and nurse/doctor notes using various fee schedules; prepares documents (e.g. charges, payments, adjustments) with Charge Description Master codes, required billing coding conventions, and batch totals.


• Assists with identification and preparation of Medicare and Medicaid payments and contractual adjustments for data entry.


• Prepares and maintains ledger/log of payments received and suspended payments; reconciles to subledger and cost report logs.


• Researches rejected or unpaid claims using aging reports; resubmits claims or inquiries; reviews adjustments; determines validity; initiates appropriate adjustments.


• Researches and resubmits rejected claims for payment; researches and resolves unmatched visit records and claims.


• Communicates and corresponds effectively with insurance carriers, intermediaries, members, in-service orientation to other departments/personnel; obtains complete and valid information; ensures collectability and maximum reimbursement of revenues.


• Maintains current knowledge of and open communication with state, federal and community agencies, insurance carriers, intermediaries and others within Kaiser organization; ensures proper and adequate exchange/interpretation of data and information; ensures maximization of payments.


• Assists supervisor in developing procedures and documentation.


• Prepares and maintains statistical data on incoming work from various departments; identifies potential operational problems; informs supervisor.


• Processes problem claims and bills with ingenuity, initiative and creativity.


• Researches documents and other available sources to determine adjustment validity; generates appropriate adjustments; submits backup to data entry for key punching function.


• Documents and records on HPMS computer system all collection action taken on individual accounts (e.g., data collection contact made, data of promised payment, credit arrangements, insurance filing date and all other pertinent information); maintains tickler system to monitor promised payment.


• Refers difficult problems to supervisor.


• Demonstrates knowledge, skills, and abilities necessary to provide culturally sensitive care and/or service.


• Performs other duties and accepts responsibility as assigned.