Claims Resolution Specialist (Hybrid)

Claims Resolution Specialist (Hybrid)

Austin Regional Clinic has been voted a top Central Texas employer by our employees for over 15 years! We are one of central Texas' largest professional medical groups with 35+ locations and we are continuing to grow. We offer the following benefits to eligible team members : Medical, Dental, Vision, Flexible Spending Accounts, PTO, 401(k), EAP, Life Insurance, Long Term Disability, Tuition Reimbursement, Child Care Assistance, Health & Fitness, Sick Child Care Assistance, Development and more.

Purpose : Responsible for processing follow up actions on claims denied for eligibility-related reasons and responding to health plan correspondence. Carries out all duties while maintaining compliance and confidentiality and promoting the mission and philosophy of the organization.

• Takes appropriate follow up action on denied claims based on the ANSI Reason Code, payer policy, eligibility and so forth. Either prepares appeals, performs write off actions or assigns financial responsibility to next party in accordance with company policy.
• Uses Epic In-Basket messages to communicate with appropriate staff to obtain authorization to edit claim data and other assistance with follow up and / or appeal actions.
• Reviews procedure and diagnosis codes to make sure they conform to third party rules and ensure appropriate reimbursement.
• Researches insurance payments and ANSI reason code denials to determine correct posting information.
• Edits claims through Correct / Report actions to reflect complete, accurate & updated information.
• Processes and submits appeals in accordance with payer policy.
• Maintains and follows up on accounts appropriately and clearly and accurately documents issues, sources and actions taken to describe activities and results in Account Contact.
• Reviews accounts for credits and requests refunds to insurance companies or patients as necessary.
• Submits EOB and other supporting documentation to the Supervisor and Team lead for approval to adjust any charges that exceed the approved threshold
• Informs and works with management team when all usual attempts to collect from third parties and / or customers have failed to result in adequate reimbursement.
• Follows up with insurance carriers on problematic coverage issues.
• Follows up with insurance carriers on problem payments and adjustments.
• Utilizes payer and clearinghouse web-sites for claims status or eligibility.
• Completes assigned department problem tickets
• Opens a weekly system batch to store correspondence & other documents; references batch number in account notes to cross reference document location.
• Opens, closes, and process batches according to departmental guidelines.
• Generates any adjustments necessary to complete posting of payments.
• Uses appropriate Epic Functions, write off codes and ANSI Remark codes when performing actions through Account Maintenance
• Adds a termination date to patient coverage when claim is denied "coverage termed."
• Reviews and follows up on Patient Account Teams' inquiries according to established policy.
• Documents daily work / tasks on weekly Excel pivot table.
• Identifies and documents new payer denial trends, and notifies supervisor for escalated follow up.
• Escalates unresolved claim denials to supervisor for follow up with health plan provider representatives.
• Performs all duties within established departmental time frames.
• Regular and dependable attendance.
• Attends required in-service / training sessions. Adheres to all company policies, including but not limited to, OSHA, HIPAA, compliance and Code of Conduct.
• Follows the core competencies set forth by the Company, which are available for review on CMSweb.

Work queue Maintenance :

Correspondence :

Other duties and responsibilities :

Qualifications :

Education and Experience :

Required : High school diploma or GED. Experience using computer data processing systems. Two (2) or more years of experience working claim denials for either professional or hospital billing.

Preferred : At least two (2) years of customer service experience. Bilingual in both Spanish and English. Experience with Epic.

Knowledge, Skills and Abilities :

Work Schedule : Monday through Friday 8am-5pm

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.