Patient Care Service Representative

Job Description:

Communicates benefit information to patients, physicians and insurers who provide insurance verification as required. Interprets medical and insurance information for clients. Responsible for case management with patients, physicians and insurers primarily over the telephone. Provides detailed, technically complex information to patients to facilitate the beneficial therapeutic relationship between the patient, provider and company. Interacts with sales, information technology and service, may interact with manufacturing.

Essential Duties and Responsibilities:

• Answers inbound and outbound calls, research, and identifies insurance to ensure compliant/proper account resolution.
• Verifies insurance eligibility and follows coordination of benefits guidelines.
• Faxes accurate and thorough Pre-Authorization Request Letters.
• Determines revenue amounts based on allowable, benefits, unit price, payer guidelines, copayment and contract pricing.
• Submits appropriate and accurate billing to Government entities and private insurance payers consistent with Federal, State and insurance specific requirements.
• Pursues supporting documentation from Sales Team to ensure all required documents are received prior to invoicing.
• Reviews prescriptions, Letters of Medical Necessity and/or Chart Notes to ensure both completeness and accuracy.
• Ensures that orders meet criteria and compliance standards, and resolves assigned denials and variances by accurately determining the root cause and collaborating to reduce the denial or variance.
• Works to resolve submission issues which can include obtaining the appropriate Medical Record documentation or validation of coding.
• Reviews orders for accuracy and completeness prior to providing the "OK to Place" and invoicing.
• Processes assigned correspondence and telephone inquiries from patients and payers in a compliant manner and promptly responds in writing or verbally.
• Appropriately challenges insurance companies by communicating information on Medical Necessity and negotiating coverage and pricing for the purchase of DJO products that meet all applicable payor guidelines.
• Serves as back-up for other PCS Representatives and their assigned region(s), as needed, to maintain timely turnaround time (TAT).
• Builds and maintains professional relationships with Sales Team(s) based upon region assignments.
• Supports Sales Team(s) by providing constant and accurate communication using online tools, email, and phone.
• Communicates with Management and Payor Development regarding payer trends.
• Communicates and escalates business concerns to Management when appropriate.
• Actively participates in process improvements and develops strategies to ensure compliance and reduce claim edits by collaborating with management and other internal departments.
• Maintains professional and technical knowledge by staying current on relevant products (both of DJO and its competitors), reviewing clinical publications/studies and establishing personal networks.
• Adheres to all internal Corporate Compliance guidelines, OIG and government health care regulations, and other payor policies.
• Treats Protected Health Information (PHI) with the strictest confidentiality in accordance with HIPAA standards.

• Minimum of 2 years of experience with compliant patient billing, customer service, claims processing or related experience in a health care environment required.
• Knowledge of ICD-10 coding, medical terminology, third party billing and collections, and managed care requirements required.
• Proficiency in Microsoft Office applications required.
• Strong attention to detail and passion for patient care and doing the right thing when decisions need to be made.
• Must have full understanding of customer service and compliant insurance follow-up processes (i.e., Billing, Collections, Managed Care, Medicare, Medicaid, and Commercial payor practices).
• Experience responding to patient and insurance inquiries preferred.
• Experience using DataWorks, TIMS, or similar case management software strongly preferred.