Credit Refund Representative

Please note: this is a temporary assignment (6 months) with potential to extend. The Credit/Refund Unit is responsible for analyzing, reviewing, and researching credit balances to determine appropriate refunds to various payees. The unit verifies the legitimacy of incoming credit and refund requests from internal and external customers and ensures the accurate processing of refunds, adjustments, and fund transfers in accordance with established guidelines, policies, procedures, and regulatory requirements. The unit works closely with UCSF Medical Center's Accounts Payable department and affiliated institutions to ensure quality, accuracy, and compliance with UCSF, MGBS, government, and HIPAA standards. The Credit/Refund Representative is responsible for resolving outstanding credit accounts through ongoing communication with insurance payers, other MGBS units, UCSF clinical departments, and external billing agents. The incumbent researches and resolves credit and refund discrepancies, demonstrates proficiency in all aspects of credit and refund processing, and consistently maintains high standards of accuracy, quality, customer service, and regulatory compliance.

• Analyze and evaluate insurance claims with credit balances using a stratified approach, as assigned by management.
• Research, review, and process insurance and patient credit balances in accordance with established Credit Balance policies and procedures.
• Research, review, and process insurance and patient refund requests in accordance with established Refund policies and procedures.
• Coordinate with the Hospital regarding the transfer of insurance and patient credit balances resulting from research and account reviews.
• Process and post refunds, adjustments, and journal transfers accurately in accordance with applicable policies and procedures.
• Apply knowledge of various payer requirements and regulations, including PPO, EPO, HMO, and commercial insurance plans.
• Communicate effectively with insurance payers, patients, UCSF departments, and external billing agents to resolve credit balance and refund inquiries.
• Utilize various computer applications and information systems, including Microsoft Excel, Word, Outlook, APeX, WebXtender, and other systems necessary for credit balance research, refund processing, journal transfers, and payment posting.
• Retrieve and verify all required account information to determine accurate credit balances and appropriate refund recipients.
• Prepare and submit refund check requests, including detailed supporting documentation, to management for review and approval.
• Communicate with insurance payers regarding the justification of payment takebacks and the resolution of unidentified payments.
• Prepare and submit refund check request batches to Medical Center Accounts Payable for processing.
• Research and diligently process returned refund checks issued by MGBS, identifying and addressing the reasons for their return.
• Prepare batch summaries, organize supporting documentation, and maintain records for filing.
• Identify and communicate potential procedural changes and process improvement opportunities to management to enhance operational efficiency.
• Actively participate in monthly Continuous Quality Improvement (CQI) and Key Performance Indicator (KPI) meetings, including monthly one-on-one meetings, as well as unit and team meetings to support ongoing learning and operational improvements.
• Perform special projects and other duties as assigned by the Assistant Manager or Manager.

Required:

• Minimum of 2–3 years of experience in a hospital or physician billing office, or an equivalent combination of education, training, and experience.
• Flexibility to orient and work at all UCSF Medical Center locations.
• Knowledge of CPT and ICD-9 or ICD-10 coding.
• Experience with denials management and all aspects of billing and follow-up.
• Proficiency in Microsoft Excel and Outlook.
• Strong organizational, interpersonal, verbal, and written communication skills.
• Ability to work effectively in a changing environment while managing multiple priorities and tasks.
• Demonstrated time management skills, including the ability to prioritize assignments and meet deadlines.
• Ability to work independently and collaboratively as part of a team.
• Ability to consistently meet productivity and quality standards.
• Strong customer service skills and a positive, professional attitude.
• Demonstrated ability to coach and mentor staff to achieve optimal results.
• Ability to establish priorities, goals, and objectives.
• Excellent attendance and reliability.

Preferred:

• Prior experience with the EPIC (APeX) system.
• Certified Professional Coder (CPC) credential.
• Associate's or bachelor's degree.