Payment Resolution Analyst

About the role

Responsible for researching and resolving all Professional Billing overpaid and underpaid balances. This role also reviews insurance underpayments to ensure claims are paid at maximum reimbursement from third‑party payers, state programs, and contracted organizations for Children’s Wisconsin and Children’s Specialty Group. Additionally, the role follows up on customer inquiries related to overpayments and underpayments.

Responsibilities

• Investigates credit balances, including research of EOBs 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 knowledge of primary care and complex specialty billing guidelines for each provider group in Professional Billing.
• Collaborates with the Payer Contracting team and stays current on managed‑care payer contracts and third‑party payer billing/reimbursement policies across all lines of business (Government, HMO, Commercial).
• Identifies coding issues related to CPT‑4, ICD‑10, and appropriate modifiers that result in overpayments or underpayments; works with leadership and coding team on resolution.
• Utilizes payer websites to verify patient insurance information, claim status, payments, denials, and appeals as necessary.
• Analyzes and investigates improper insurance credits, tracking trends associated with payers.
• Keeps leads and management apprised of identified issues impacting reimbursement.
• Works with Lead and Manager to resolve claim/credit issues.
• Submits written and online correspondence and appeals to payers when disputing a refund/recoup request to obtain maximum reimbursement.
• Maintains productivity and quality standards as set by management.

Requirements

• Education: High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED) required.
• Experience: 2+ years of experience in professional billing and follow‑up required. Pediatric experience preferred. Prior experience in a large health system working with professional billing claims and functions preferred. Medical billing experience preferred. Prior credit resolution/payment posting experience preferred. Experience in Epic Resolute preferred.
• Knowledge, Skills and Abilities: Working knowledge of medical terminology, ICD‑10 and CPT. Excellent verbal and written communication skills. Ability to work independently with minimal supervision. Interpersonal skills necessary to efficiently respond to questions from patients, parents, clinic staff, and insurance companies to effectively resolve billing issues. Proficient in Microsoft Office applications and technology skills required to perform duties. Ability to multi‑task and function effectively in a team environment while maintaining effective relationships with coworkers, patients, physicians, management, staff, and other customers.