Private Insurance Accounts Representative

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The Private Insurance Accounts Representative (PIAR) is responsible for timely collection of account balances from Medicare and private (non-contracted) insurance carriers and patients. The PIAR also processes returned checks and provides clerical and administrative support relating to Medicare and private insurance issues to insurance carriers, patients, clinics and administrative personnel. Based on business requirements, on occasion, PIAR will be expected to perform other duties within the billing office as assigned by Private Billing Section Supervisor (PBSS).

Work Hours:

The normal work-week is 35-40 hours/week full-time, Monday through Friday as scheduled. Occasional overtime or variations (including evenings and Saturdays) may be required or authorized.

Education & Training:

  • Must have High School diploma or GED
  • Must have one of the following:
    • 2 years of related experience
    • Certificate in related field plus 1 year related work experience

Position Advancement:

The PIAR has the opportunity for advancement to the Private Insurance Collector (PIC) position after meeting the following requirements:

  1. Must be in the PIAR position for 2 years
  • Must score at least 3.40 on annual date-in-position evaluation for last 2 years
  • Must not have a Performance Improvement Plan (PIP) in last 12 months
  • Must have a good time and attendance record with no suspensions in last 12 months
  • Must not have written disciplinary action in personnel file in last 12 months
  • Must have Department Manager or PBSS recommendation for promotion


  1. Must have a minimum of 4 years applicable medical billing and/or collections and 6 months in the PIAR position:
  • Must score at least 3.40 on all TMC evaluations since beginning of employment
  • Must not have received any time and attendance memos in the last 6 months
  • Must not have any written disciplinary action in personnel file
  • Must not have a performance improvement plan since beginning of employment
  • Must have Department Manager or PBSS recommendation for promotion

Essential Knowledge, Skills & Abilities:

  • Must possess good customer service skills
  • Basic knowledge of Medicare and managed care insurance required
  • Basic knowledge of CPT and ICD codes and modifiers required
  • Basic knowledge of medical terminology, its spelling and abbreviations required
  • Good computer and keyboarding skills: Microsoft Word required; Excel and Outlook preferred
  • Must have a working knowledge of Accounts Receivable (AR)
  • Medical software experience required, current TMC medical software experience preferred
  • Must have a working knowledge of EDI processing and medical applications systems skills
  • Must be organized, detail oriented and able to adapt quickly to stressful work environment
  • Must be able to work in team environment, as well as independently
  • Must be able to communicate effectively in English (grammar, spelling, writing, and verbal skills)
  • Must possess effective reasoning and deductive ability
  • Must be able to read, correctly interpret and follow written guidelines/protocols
  • Must be able to learn and apply new skills
  • Must be able to manage time to ensure completion of tasks, while paying attention to detail
  • Must be able to prioritize duties to understand what duties take priority and when issues need escalation
  • Must maintain confidentiality when dealing with medical information
  • Medical transcription experience helpful
  • Experience using a 10-key adding machine preferred
  • Ability to communicate in Spanish helpful

Essential Job Functions & Duties:

  1. Routinely alphabetizes and files correspondence received as needed
  2. Prepares letters and bills (copying, stapling and stuffing)
  3. Creates and maintains files for appeals and correspondence
  4. Pulls, photocopies and organizes records or faxes (charts, Explanation of Benefits (EOBs) and receivables, etc.) as requested
  5. Logs into phone queue daily
  6. Handles patient payments (credit card, check and cash) by phone or walk-in
  7. Generates insurance claims or patient statements as needed


  1. Works Medicare and non-contracted managed care accounts in NextGen
    1. Creates and maintains files for appeals and correspondence
    2. Calls insurance carriers or accesses website for claim status
    3. Verifies eligibility and benefits
    4. Adds appropriate adjusting or transfers transactions
    5. Files or refiles claims
    6. Appeals claims
    7. Identifies accounts for outside collection and adds appropriate transactions
    8. Documents actions on accounts
    9. Processes the seasonal flu vaccine billing for Medicare patients; reconciles the clinic worksheets to charges processed
  2. Updates all actions taken with clear and concise notes, updates the worklog status and follow up date (NextGen)
  3. Reassigns WorkLog Tasks as needed or any tasks not properly assigned
  4. Works the HMO-PPO Ins Bal Task, MCR-NC Ins Bal task
    1. Follows up and takes necessary action needed for payment on claim
    2. Re-files corrected claim and/or adjusts as needed
    3. Identifies insurance determinations that need to be appealed and submits with appropriate documentation
    4. Documents action taken; updates task to appropriate status
    5. Sets follow up date according to schedule provided
    6. Completes within 30 days from create date or sooner
  5. Works RealMed Edit/Erred claims to ensure timely submission of claims within three days of submit date. Any corrections must also be updated in NextGen
    1. Updates RealMed Erred claims with the necessary information to reduce processing time
    2. Ensures all eligibility is verified and claims addresses are set to process in the most efficient way (electronic whenever possible)
    3. Appropriately uses “delete” claims from RealMed; understands that may result in additional time delays and only deletes as indicated by the edit issue
    4. Any corrections in RealMed must also be updated in NextGen
    5. RealMed Edit/Erred claims worked within three days of submit date
  6. Processes Final Demand Tasks daily not to exceed 14 days from task create date
    1. Reviews report of balances that qualify for Final Demand Letter to be sent to patient
    2. Makes necessary corrections on those that do not qualify for Final Demand Letter
    3. Checks mailing address
    4. Documents action taken; updates task status and task log accordingly
    5. Works the encounters with bad addresses; researches in PIW; corrects and updates
    6. Transfers corresponding credits to balances as needed
    7. Follow up dates should not exceed 10 days from due date
  7. Works the Prelist tasks daily not to exceed 14 days from task create date
    1. Reviews the “Not Started”
    2. Processes to Collections all balances
    3. Adds the required transactions and fees prior to sending
    4. Documents action taken
    5. Updates status
    6. Expired follow up dates should not exceed 10 days
  8. Identifies and resolves problems
    1. Identifies recurring processing errors and work with the corresponding teams (internal or external) for resolution
    2. Documents issues in patient accounts and maintain record of problems and status of resolution
    3. Discusses recurring problems with PBSS to ensure appropriate corrective action is taken
  9. Processes daily Non-Payment EOB’s as assigned to be completed by no more than 3 days from receipt date
    1. Posts non-revenue actions to patient accounts (i.e., applied to deductible, need more information from patient)
    2. Posts routine insurance disallowances to patient accounts according to contractually allowed amounts
  10. Maintains and improves knowledge of Medicare Rules and Procedures through ongoing training and education
  11. Processes returned checks
    1. Reviews information from outside vendor
    2. Records returned check on patient account
    3. Sets alert notes
    4. Processes checks that cannot be processed by outside vendor
    5. Records returned check
    6. Adds OI15 adjustment
    7. Adds the original charge to the encounter, equal to the amount of the check (NSF check reversal)
  1. Interacts with staff members professionally
  2. Follows company policies and procedures (time and attendance, dress code, etc)
  3. Promotes teamwork and facilitate company goals
  4. Answers incoming calls prior to 5 rings
  5. Returns customer messages within 2 working days
  6. No more than 3 agency cancels in a three month period (errors in sending to collections)
  7. No excessive past filing deadlines or past appeals deadlines written off in a given month
  8. Makes sure all actions taken on an account are documented
  9. Daily correspondence (Non-Payment EOBs) should be completed by no more than 3 days from the receipt date
  10. Works a minimum of 210 accounts/encounters per week
  11. Consistently provide PBSS with feedback on their AR and how to improve efforts
  12. Correctly uses office equipment
  13. Works safely
  14. Other duties as assigned
  15. Must be punctual and reliable in attendance

Customer Service Skills:

  1. Answers department phones
  2. Answers questions from internal and external customers in a professional manner
  3. Responds to request from internal and external customers in a professional and timely manner
  4. Meets the service expectations of patients
  5. Meets the service expectations of internal customers
  6. Meets the service expectations by external customers
  7. Resolves problems identified by patients
  8. Resolves problems identified by internal customers
  9. Resolves problems identified by external customers
  10. Follows through on commitments
  11. Interacts with co-workers in other departments in a manner that promotes teamwork and facilitates company goals

Working Conditions & Risks:

Work is indoors in a well lighted, and seasonally heated and cooled business office. Job hazards are estimated to be minimal (low risk). Potential risk exists from accidents while using routine office equipment.

Physical Requirements:

Position requires occasional need to lift heavy (30-50lbs) boxes from chest height to floor to chest height. Prolonged sitting, sorting, moving about, and intermittent typing approximately 4-6 hours per day routinely. Good vision, good hearing, and clear speech required (correctable). Repetitive motions consist of extended periods of upper body and upper limb movements (arms, hands, and wrists) prolonged use of phone and computer.

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