Claim Resolution Rep IV

Job Location: 905 Elmgrove Rd, Rochester, New York, United States of America, 14624

Worker Subtype: Regular, Full time
Scheduled Weekly Hours: 40
Department: Patient Financial Services
Work Shift: Day
Compensation Range: $21.40 - $28.89

Responsibilities

• Performs follow-up activities designed to bring all open account receivables to successful closure and obtain maximum revenue collection.
• Researches, corrects, resubmits claims, submits appeals, and takes timely and routine action to resolve unpaid claims.
• Mentors and trains new or lower-level staff.
• Location: Rochester Tech Park (RTP), Gates, NY - Remote options available after in-person training. Occasional onsite meetings/work at RTP are required. Remote location must be within 2 hours of RTP and within New York State.
• Independently determines the most effective method to follow up on disputed, unpaid, underpaid, or overpaid insurance or contracted service accounts to bring about prompt account resolution and revenue collection from complex claims, high-dollar claims, and specialized services.
• Identifies and resolves problems related to primary and secondary accounts which are disputed, unpaid, underpaid, or overpaid. Determines cause of problem and initiates corrective action through reviews of electronic medical records.
• Works to confer with external agencies.
• Analyzes accounts and determines if correct proration of revenue has been collected, using detailed understanding and application of all payer contracts. Contacts applicable agency, payer, or department for resolution.
• Decides when resubmitting efforts are complete, including writing an appeal using applicable content and supporting documentation to appropriately influence the highest level of revenue.
• Acts as a resource for questions from assigned collection and billing staff on payer policies, procedures, and methods of revenue collection.
• Trains new staff on the use of the billing application, payer systems, and clearinghouse systems. Demonstrates how to apply the knowledge of payer contracts and resources to resolve disputed, unpaid, underpaid, or overpaid accounts.
• Provides feedback to leadership on results of training of new and existing staff. Provides input for performance assessments based on observation, questions, and quality reviews of work performed.
• Acts as area leader, when needed, including responding to payers, patients, and issues referred to the area from hospital departments or department representatives.
• Researches and responds to clinical department inquiries on complex, high-dollar, and specialized accounts and status of collection activities affecting departmental revenue.
• Assesses if/when patients are contacted. Resolves complex, high-dollar, and specialized claim resolution issues due to coordination of benefits, eligibility issues, and authorizations.
• Resolves accounts identified in third-party audits involving retroactive approvals, resulting in adjustments, refunds, and subsequent secondary billing.
• Researches, verifies, and/or obtains authorizations post-claim submittal. Determines allocation of reimbursement applicable to multiple providers for global transplant payments and initiates transfer of money to each payer.
• Identifies need for in-person meetings and phone conferences with third-party insurance representatives due to claim and system issues requiring prompt attention for complex high-dollar accounts.
• Prepares information for and attends meetings with third-party insurance representatives on claims and systems issues for scheduled in-person meetings and phone conferences regarding complex high-dollar claims.
• Identifies and clarifies issues that require management and intervention to avoid loss of revenue. Recommends filing of a formal complaint with the State’s regulation commission or agency.
• Determines when to change the account to a self-pay financial class after a review of previous efforts has not resulted in revenue collection and further attempts would not be successful without patient intervention.
• Researches and initiates suggestions to leadership to streamline processes and training materials.
• Performs coverage for other positions as needed. Performs administrative office tasks and maintains records.
• Other duties as assigned.

Requirements

• Associate's degree and 3 years of relevant experience required.
• Or equivalent combination of education and experience.