Claim Resolution Rep III

Job Title

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share : equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location : Rochester Technology Park

Opening : Regular

Time Type : Full time

Scheduled Weekly Hours : 40

Department : 500011 Patient Financial Services

Work Shift : UR - Day (United States of America)

Range : UR URC 205 H

Compensation Range : $19.62 - $26.49

Responsibilities

General Purpose : 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. Resolves complex claims. Acts as a resource for lower level staff.

Essential Functions :

• 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.
• Assists department leadership with credit balances account reviews / resolutions and all audits.
• Coordinates response and resolution to 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.
• Assists with all audits as needed.

Minimum Education & Experience : Associate's degree and 2 years of relevant experience required or equivalent combination of education and experience.

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University's Mission to Learn, Discover, Heal, Create and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military / veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.