PAYER RELATIONS REPRESENTATIVE - Riverside HealthCare : Job Details

Job Type Full-time Description The Payer Relations Representative serves as the primary liaison between Riverside Healthcare and contracted and non-contracted insurance payers, ensuring timely and accurate reimbursement through proactive communication and effective resolution of payment issues. This role is integral in maintaining payer relationships, addressing claims discrepancies, and supporting compliance with contractual agreements and revenue integrity processes. Essential Job Duties

• Payer Communication and Coordination
• Act as the main point of contact for all payer-related inquiries and escalations.
• Develop and sustain strong working relationships with insurance representatives.
• Maintains listing of outstanding accounts with each payer and be the liaison between the payers and internal departments regarding the accounts.
• Provide contract updates to third party vendors utilized claim review, price transparency, etc.
• Claims Management
• Monitor and address denied, underpaid, or delayed claims to ensure accurate and timely payments.
• Collaborate with internal departments to investigate and resolve claims issues.
• Contract Compliance
• Review payer contracts and policies to ensure Riverside Healthcare's compliance and maximize reimbursement.
• Communicate updates on contract changes, fee schedules, and payer policies to relevant stakeholders.
• Reporting and Analysis
• Analyze payer performance trends and report findings to leadership.
• Identify opportunities to improve processes and enhance payer relationships.
• Maintain updated consolidated spreadsheets related to negotiated contract information to provide to senior leadership.
• Review all adjustments related to payer deficiencies for accuracy and run analysis on these adjustments for strategic improvement.
• Training and Education
• Educate staff on payer policies, billing requirements, and revenue integrity initiatives.
• Provide support and guidance on best practices for claims management.

Nonessential Tasks

• Participate in revenue cycle team meetings and strategic planning sessions.
• Support special projects related to revenue integrity and payer relations as needed.
• Perform other accounts functions as needed to support the overall financial operations of the organization.

Requirements Required Experience:

• Minimum of 4 years of experience in payer relations, healthcare billing, or revenue cycle management.
• Familiarity with medical billing codes (CPT, ICD-10) and payer guidelines.

Preferred Experience:

• Strong problem-solving and negotiation skills.
• Proficiency in revenue cycle systems and Microsoft Office applications.
• Excellent interpersonal and communication abilities to foster payer partnerships.

Preferred Education/Licensure:

• Associate's degree in Healthcare Administration, Business, or related field is preferred.
• Certification in Medical Billing or Coding (e.g., CPC, CCS) is preferred but not required.

Exposure/Sensory Requirements Exposure to: Chemicals: Refer to MSDS Sheets Video Display Terminals: Extreme Blood and Body Fluids: None TB or Airborne Pathogens: None Sensory requirements (speech, vision, smell, hearing, touch): Speech: Needed for presentations/training, telephone communication, facilitate meetings. Vision: Needed to read memos and literature Smell: Helpful to note presence of electrical/fire hazard. Hearing: Needed for telephone communication, meetings, alarms and listening to employee concerns. Touch: Needed to write, computer entry, filing. Activity/Lifting Requirements Average Hours per Week: 40 Shift: Days Percentage of time during the normal workday the employee is required to: Sit: 90% Twist: 5% Stand: 0% Crawl: 0% Walk: 0% Kneel: 0% Lift: 0% Drive: 1% Squat: 0% Climb: 0% Bend: 0% Reach above shoulders: 0% The weight required to be lifted each normal workday according to the continuum described below: Up to 10 lbs: Occasionally Up to 20 lbs: Occasionally Up to 35 lbs: Not Required Up to 50 lbs: Not Required Up to 75 lbs: Not Required Up to 100 lbs: Not Required Over 100 lbs: Not Required Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.): Lift reports to and from storage files and cabinets. Maximum consecutive time (minutes) during the normal workday for each activity: Sit: 120 Twist: 5 Stand: 0 Crawl: 0 Walk: 0 Kneel: 0 Lift: 0 Drive: 0 Squat: 0 Climb: 0 Bend: 0 Reach above shoulders: 0 Repetitive use of hands (Frequency indicated): Simple grasp up to 10 lbs. Normal weight: 5-10lbs Pushing & pulling Normal weight: 20lbs Fine Manipulation: Calculator, keyboard. Repetitive use of foot or feet in operating machine control: None Environmental Factors & Special Hazards Environmental Factors (Time Spent): Inside hours: 8 Outside hours : 0 Temperature: Normal Range Lighting: Average Noise levels: Average Humidity: Dry Atmosphere: Dust, poor ventilation Special Hazards: None Protective Clothing Required: None Salary Description $25.43 - $31.78