Claims Resolution Specialist (Hybrid)

Claims Resolution Specialist (Hybrid)

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, and 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 websites 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 processes 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.

Thoroughly researches reasons for denied claims in assigned work queues to resolve outstanding balances.

Acts upon payer correspondence in a timely manner to avoid posted deadlines.

Utilizes the work queue activity to track follow up activities.

Manages follow-up work queues as assigned using tools and resources provided by leadership.

Places account notes in the account to document all activities and results.

Maintains correspondence per department standard.

Posts zero payment EOBs / correspondence using a Payment Posting Batch.

Reviews work queue summary for each correspondence account and completes from work queues as appropriate.

Responds to Patient / Customer to confirm receipt of / or provide resolution to written correspondence.

Forwards requests for Registration verification and updates to the Registration Team.

Provides back up to Customer Service and assistance to the Central Registration call center.

Meets job standards for Patient Registration and Posting positions.

Keeps complete, accessible, and dated files.

Verifies insurance eligibility and sets up accounts by account type classifications.

Provides workload statistic reports to management team.

Assists in training other staff members.

Provides assistance to coworkers as requested and / or necessary.

Performs other duties as assigned.

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 :

• Knowledge of and / or experience with Medicare, Medicaid, and commercial insurance plan registration, and eligibility verification.
• Knowledge of and / or experience with procedural and diagnostic coding.
• Knowledge of ANSI codes.
• Knowledge of claim denial management.
• Knowledge of patient copay vs. cost share responsibility.
• Ability to engage others, listen, and adapt response to meet others' needs.
• Ability to align own actions with those of other team members committed to common goals.
• Excellent computer and keyboarding skills, including familiarity with Windows.
• Excellent verbal and written communication skills.
• Ability to interpret payer explanation of benefits.
• Ability to manage competing priorities.
• Ability to perform job duties in a professional manner at all times.
• Ability to understand, recall, and apply oral and / or written instructions or other information.
• Ability to organize thoughts and ideas into understandable terminology.
• Ability to apply common sense in performing job.
• Experience with Microsoft Office.
• Experience with Adobe.

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.