Account Resolution Representative

Job Summary

The Account Resolution Representative is responsible for obtaining fiscal resolution of Government, Medicaid HMO, and Commercial insurance claims. This involves following governmental regulations and guidelines, commercial insurance contractual agreements, investigating claims denials, and ensuring timely claim submission.

Essential Functions

• Utilizes Hospital computer billing system(s) (Epic) to follow-up on unpaid, underpaid, and credit balance claims ensuring timely filing guidelines are followed.
• Verifies accounts are with the correct payer liability and balance with the payer by utilizing payer websites and electronic eligibility clearinghouses to verify the accuracy of the patient insurance information.
• Ensures timely claim submission(s).
• Performs comprehensive collection actions including contacting patients/parents, insurance companies, correcting and resubmitting claims.
• Drafts documentation in the appropriate system.
• Responds to and resolves claim denials by filing appeals in accordance with individual payer requirements.
• Identifies and escalates denials to RN Auditors per applicable departmental policies and procedures.
• Analyzes payer errors and/or denials to identify trends. Escalates trends and high volume issues to Lead and Management to lessen impact on Cash flow.
• Validates and facilitates release of information (ROI) requests for patient medical records from external requestors (insurance payers and third-party vendors) in a timely and efficient manner.
• Pairs with Release of Information team and vendor to ensure deadlines related to release of information are met to avoid denials and financial risks to Children’s Wisconsin.
• Maintains accuracy and quality of the medical records processed and released.
• Investigates credit balances to include research of EOB’s and verification of accurate contractual discounts.
• Reviews written requests for refunds from insurance companies and other payers to protect CHW’s financial interests and completes appropriate paperwork for management authorization.
• Maintains current knowledge of all payer contracts and third party payer billing/reimbursement policies for all lines of business (Government, HMO and Commercial).
• Reviews and enters adjustment requests as appropriate using departmental specific adjustment codes.

Legacy Essential Functions

• Works with Lead to resolve complex claims issues using all available departmental resources.
• Complies with productivity standards while maintaining quality levels.
• Documents all work in accordance with departmental standards.
• Understands and adheres to the Children’s Organizational Code of Ethics and ensures personal actions comply with policies, regulations, and laws applicable to Children's business.
• Utilizes appropriate tools and resources to assist in the processing and follow up of claims, such as Adobe, RightFax and payer and vendor websites.

Education

• High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED)
• Associate's Degree or higher in Medical Billing and Coding, in Health information Management, Healthcare Services Management, Health Information Technology
• Preferred: Associate's Degree in a business related field

Experience

• 2+ years experience in claims follow up, HCFAs and/or UB-04s (preferably in a hospital setting) including insurance reimbursement procedures and comprehension of insurance EOB’s
• Required: General pediatric and/or pediatric subspecialty experience
• Prior Epic experience preferred

Knowledge, Skills and Abilities

• Basic knowledge of medical records and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Basic knowledge and understanding of medical terminology and human anatomy and disease processes.
• Basic knowledge of ICD-10, CPT and HCPCS level II codes.
• Accuracy and attention to detail.
• Problem solving skills including the ability to handle difficult situations.
• Prioritization, organization, and meeting deadlines.
• Excellent verbal and written communication skills.
• Independence, teamwork, and relationship building.
• Advanced computer skills including in using Microsoft Office products, Adobe, electronic mail and/or electronic health information records systems and proficient keyboarding skills.

Remote Position!

This position offers a flexible schedule and remote work options.

Certifications/Licenses

No specific certifications/licenses are required for this position.