PBO Project Specialist

Prisma Health
US - South Carolina - West Columbia
November 16, 2024

Inspire health. Serve with compassion. Be the difference.

Job Summary

Oversees the daily operations of Managed Care/Credentialing functions supporting the Prisma Health providers.

This is a remote position.

Essential Functions

Payer Logs

Maintains payer issues log to track payer denial trends and assist with Prisma Health's overall Denial Prevention efforts.This is a very intense time-controlled process. Requiring constant gathering of information from various users of the Epic system for "all" Service Areas" in both Markets and all contracted payer groups.
Payor Log Call monitoring, questions and communications with our Prisma Health Delegated Payors.
Research issues to ensure proper billing and coding has occurred. Presents issues at monthly payer meetings.
Works closely with Contracting Department, Coding Department, Billing Department and Patient Access Department on development of payer rules and guidelines for Epic Application.
Oversees weekly management payor Logs and provides management with an up-to-date status of items greater than allowed follow up time for user who are adding to log and then follow up with emails to users for status.
Reviews payer websites for new or revised content providing updates to Coding departments and/or PH practices.
Maintains a working knowledge of third-party payment requirements, including (as applicable) Medicare, Medicaid, Managed Care Organizations, private insurers, and Worker's Compensation carriers. Provides timely education to inform team members of relevant changes and developments in payor requirements. Proactively pivots to meet the changing needs of payor requirements to maximize cash flow for the organization.
Attends assigned payer education meetings and provides updates to PH PBO and Practice Offices.
Works closely with Business Management Lead to identify discrepancies in Reimbursement Schedules and actual payments.
Performs audit on recoveries that are received via contract management system to assure volumes and dollar amounts being reported are accurate and valid. (35%)

Coverage Detection (Waystar)

Works Coverage Detection reports weekly, delivered by Waystar for Prisma Health PB practices, as assigned. Keeps management updated on progress. (20%)

Charity, Access Health,and Client Submitter accounts

Works assigned Epic WQ's for Bad Debt, Financial Assistance, Access Health, Client Submitter accounts for Free Medical Clinics, Adjustments, Registrations, and corrections.
Works very closely with HB and our assigned IT Analysis to identifying issues with Charity Trackers and ensure PB charges are generated through the tracker(s) correctly.
Handles all calls, emails, and inquiries for all PH PB Epic users with questions regarding FAP/ all charity programs. (20%)

Duplicate Guarantor WQ's/HIM Clinical Information Billing Correction Request

Daily assignments to maintain needed corrections for completing Duplicate Guarantor registrations errors causing wrongful billing on incorrect accounts.
Assist HIM Clinical Information Analyst with moves or corrections after Chart Audits needed changes are discovered. (10%)

Experian/Payment Variances

Works closely with our Managed Care Department and Experian assigned team for Payment Variances, under payments. Conducts monthly meetings with Experian Manager.
Responsible for ensuring Experian AR Staff is properly trained and complies with Prisma's rules for access to Epic and Contract Manager (10%)

Friday Highlights

Compiles payer information from week to week and publishes a document "Friday Highlights" containing Payer Updates and shares with PH Directors, Managers and all PBO staff.

Managed Care/Credentialing Monthly Calls/Policy Implementation Calls/ Special Projects as assigned.

Monthly calls for Credentialing to report Payor feedback and issues.
PH PolicyTech calls to provide representation from the PB side.

Performs other duties as assigned.

Supervisory/Management Responsibilities

This is a non-management job that report to a supervisor, manager, director or executive.

Minimum Requirements

Education - High School diploma or equivalent OR post-high school diploma/highest degree earned
Experience - healthcare revenue cycle, billing, collections, denials, and appeals management preferred. Other Financial experience may be considered in lieu of revenue cycle experience

In Lieu Of The Above Minimum Requirements

In lieu of the educational and experience requirements noted above, a bachelor's degree in business management, finance, accounting, or other related field and 1 year of healthcare revenue cycle experience such as billing, collections, denials and/or appeals (with previous lead supervisory

or consulting experience preferred).

Required Certifications/Registrations/Licenses

N/A

Knowledge, Skills and Abilities

Proficiency in Microsoft Office suite
Excellent organization and time management skills, and the ability to effectively establish priorities.
Superior written and verbal communication skills required
Strong attention to detail, research and follow up skills
Medical Terminology preferred
Coding knowledge preferred
Ability to work both independently and in a team setting

Work Shift

Day (United States of America)

Location

Corporate

Facility

7001 Corporate

Department

70019216 PBO Internal Medicine/Psych A/R Team

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.

Read the full job description and apply online on the recuiter's web-site

PBO Project Specialist

PBO Project Specialist

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