Account Resolution Representative Senior

Job Summary

Responsible for the review, follow-up and collection of Government, HMO, and Commercial insurance accounts receivable. This role performs comprehensive follow-up activities that facilitates cash collections and ensures that claims are paid according to contract or at the accepted reimbursement dollar amount. The Sr. Account Resolution Rep is generally responsible for inpatient, surgical, and oncology accounts but may be called on to assist with other patient claims.

Essential Functions

• Utilizes hospital computer billing system(s) to follow-up on unpaid, underpaid, and credit balance accounts.
• Performs various collection actions including contacting patients/parents, insurance companies, correcting and resubmitting claims and filing appeals in order to achieve claim resolution.
• Investigates credit balances to include research of EOB’s and verification of accurate contractual discounts.
• Review 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 managed care payer contracts and third party payer billing/ reimbursement policies for all lines of business (Government, HMO and Commercial).
• Utilizes payer websites and electronic eligibility clearinghouses to verify the accuracy of patient insurance information and check claims payment status.
• Fills online and/or paper appeals as necessary to obtain proper payment on claims.
• Analyzes payer errors and/or denials to identify trends.
• Keeps Lead and Management informed of issues that impact cash flow.
• Prepares month-end contractual reports for the Finance Department and other statistical reports as needed.
• Handles outside audits and edits of charges.
• Reviews and recommends write off of claims to management as appropriate.

Education

High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED) Required

Experience

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

Preferred

• Working knowledge of medical terminology, ICD-9, CPT and HCPCS level II codes
• Prior EPIC, QSI or IDX experience

Knowledge, Skills, and Abilities

• Excellent verbal and written communication skills.
• Bilingual skills a plus.
• Strong analytical skills and ability to perform non-complex arithmetic calculations when determining contractual allowances.
• Ability to work independently with minimal supervision.
• Proficient in Microsoft Office applications and technology skills required to perform duties.

Required for All Jobs

• This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that may be requested in the performance of this job.
• Employment is at-will.
• This document does not create an employment contract, implied or otherwise.
• Children's Wisconsin is an equal opportunity / affirmative action employer. We are committed to creating a diverse and inclusive environment for all employees. We treat everyone with dignity, respect, and fairness. We do not discriminate against any person on the basis of race, color, religion, sex, gender, gender identity and/or expression, sexual orientation, national origin, age, disability, veteran status, or any other status or condition protected by the law.

Certifications/Licenses

• Professional certification in claims processing through HFMA or AHAAM is desired.