Clm Resltion Rep III, Hosp/Prv

Responsibilities

• Performs follow-up activities designed to bring all open account receivables to successful closure.
• Responsible for an effective claims follow-up to obtain maximum revenue collection.
• Researches, corrects, resubmits claims, submits appeals and takes timely and routine action to resolve unpaid claims.
• Solves complex claims.
• Acts as a resource for lower level staff.

Requirements

• Completes follow up activities on denied, unpaid, or underpaid accounts, as well as contacts payer representatives to research and resubmit rejected claims to obtain and verify insurance coverage.
• Follows up on unpaid accounts working claims.
• Reviews reasons for claim denial.
• Reviews payer website or contacts payer representatives to determine why claims are not paid.
• Determines steps necessary to secure payment and completes and documents follow up by resubmitting claim or deferring tasks.
• Researches and calculates under or overpaid claims; determines final resolution.
• Contacts payers on incorrectly paid claims completing resolution and adjudication.
• Adjusts accounts or processes insurance refund credits.
• Reviews and advises leadership on incorrectly paid claims from specific payers.
• Works with leadership on communication to payer representatives regarding payment trends and issues.
• Bills primary and secondary claims to insurance.
• Identifies and clarifies billing issues, payment variances, and/or trends that require management intervention.
• Affords assistance to department leadership with credit balances account reviews/resolutions and all audits.
• Coincides with Medicaid and Medicare credit balances.
• Requests insurance adjustments or retractions.
• Reviews and works all insurance credits in electronic health record.
• Enters electronic health record notes, documenting actions taken.
• Researches and responds to third party correspondence, receives phone calls, and explains policies and procedures involving routine and non-routine situations.
• Assists with patient related questions.
• Communicates and coordinates with other departments to resolve claim issues.
• Affords assistance with all audits as needed.

Qualifications

• Associate's degree and 2 years of relevant experience required
• Or equivalent combination of education and experience