Children's Wisconsin
**Job Summary:**
The Account Resolution Representative is responsible for obtaining fiscal resolution of Government, Medicaid HMO, and Commercial insurance claims. Fiscal resolution is accomplished through following governmental regulations and guidelines & commercial insurance contractual agreements to ensure facility is receiving proper payment for services rendered. The Account Resolution Representative is responsible for investigation of claims denials, insurance processing errors, & open no response claims; in addition to verification accounts are with the correct payer liability and balance. The role also requires follow up on previously actioned on denials, escalation of stalled claims, and identification of payer specific trends to escalate with the Hospital Billing leadership team.
**Essential Functions:*** Utilizes Hospital computer billing system(s) (Epic) to follow-up on unpaid, underpaid, and credit balance claims ensuring timely filing guidelines are followed.* Verifies accounts are with the correct payer liability and balance with the payer by utilizing payer websites and electronic eligibility clearinghouses to verify the accuracy of the patient insurance information. Ensures timely claim submission(s).* Performs comprehensive collection actions including contacting patients/parents, insurance companies, correcting and resubmitting claims. Documents activities in the appropriate system.* Responsible for responding to and resolving claim denials by filing appeals in accordance with individual payer requirements.* Identifies and escalates denials to RN Auditors per applicable departmental policies and procedures.* Analyzes payer errors and/or denials to identify trends. Escalates trends and high volume issues to Lead and Management to lessen impact on Cash flow.* Validates and facilitates release of information (ROI) requests for patient medical records from external requestors (insurance payers and third-party vendors) in a timely and efficient manner. Partners with Release of Information team and vendor to ensure deadlines related to release of information are met to avoid denials and financial risks to Children’s Wisconsin. Ensures accuracy and quality of the medical records processed and released.* Investigates credit balances to include research of EOB’s and verification of accurate contractual discounts. Review written requests for refunds from insurance companies and other payers to protect CHW’s financial interests and completes appropriate paperwork for management authorization.* Maintains current knowledge of all payer contracts and third party payer billing/ reimbursement policies for all lines of business (Government, HMO and Commercial).* Reviews and enters adjustment requests as appropriate using departmental specific adjustment codes.* 2+ years experience in claims follow up , HCFAs and/or UB-04’s (preferably in a hospital setting) including insurance reimbursement procedures and comprehension of insurance EOB’s Required* General pediatric and/or pediatric subspecialty experience Preferred* Prior Epic experience Preferred* Basic knowledge of medical records and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).* Basic knowledge and understanding of medical terminology and human anatomy and disease processes.* Basic knowledge of ICD-10, CPT and HCPCS level II codes.* Demonstrates accuracy and attention to detail.* Demonstrated strong problem solving skills including the ability to handle difficult situations.* Ability to prioritize, organize and meet deadlines.* Excellent verbal and written communication skills.* Ability to work independently with minimal supervision.* Comfortable in both making decisions and acting.* Ability to multi-task and function effectively in a team environment and maintain effective relationships with coworkers, vendors and payers.* Advanced computer skills including in using Microsoft Office products, Adobe, electronic mail and/or electronic health information records systems and proficient keyboarding skills.* This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that may be requested in the performance of this job.* Employment is at-will. This document does not create an employment contract, implied or otherwise. #J-18808-Ljbffr
The Account Resolution Representative is responsible for obtaining fiscal resolution of Government, Medicaid HMO, and Commercial insurance claims. Fiscal resolution is accomplished through following governmental regulations and guidelines & commercial insurance contractual agreements to ensure facility is receiving proper payment for services rendered. The Account Resolution Representative is responsible for investigation of claims denials, insurance processing errors, & open no response claims; in addition to verification accounts are with the correct payer liability and balance. The role also requires follow up on previously actioned on denials, escalation of stalled claims, and identification of payer specific trends to escalate with the Hospital Billing leadership team.
**Essential Functions:*** Utilizes Hospital computer billing system(s) (Epic) to follow-up on unpaid, underpaid, and credit balance claims ensuring timely filing guidelines are followed.* Verifies accounts are with the correct payer liability and balance with the payer by utilizing payer websites and electronic eligibility clearinghouses to verify the accuracy of the patient insurance information. Ensures timely claim submission(s).* Performs comprehensive collection actions including contacting patients/parents, insurance companies, correcting and resubmitting claims. Documents activities in the appropriate system.* Responsible for responding to and resolving claim denials by filing appeals in accordance with individual payer requirements.* Identifies and escalates denials to RN Auditors per applicable departmental policies and procedures.* Analyzes payer errors and/or denials to identify trends. Escalates trends and high volume issues to Lead and Management to lessen impact on Cash flow.* Validates and facilitates release of information (ROI) requests for patient medical records from external requestors (insurance payers and third-party vendors) in a timely and efficient manner. Partners with Release of Information team and vendor to ensure deadlines related to release of information are met to avoid denials and financial risks to Children’s Wisconsin. Ensures accuracy and quality of the medical records processed and released.* Investigates credit balances to include research of EOB’s and verification of accurate contractual discounts. Review written requests for refunds from insurance companies and other payers to protect CHW’s financial interests and completes appropriate paperwork for management authorization.* Maintains current knowledge of all payer contracts and third party payer billing/ reimbursement policies for all lines of business (Government, HMO and Commercial).* Reviews and enters adjustment requests as appropriate using departmental specific adjustment codes.* 2+ years experience in claims follow up , HCFAs and/or UB-04’s (preferably in a hospital setting) including insurance reimbursement procedures and comprehension of insurance EOB’s Required* General pediatric and/or pediatric subspecialty experience Preferred* Prior Epic experience Preferred* Basic knowledge of medical records and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).* Basic knowledge and understanding of medical terminology and human anatomy and disease processes.* Basic knowledge of ICD-10, CPT and HCPCS level II codes.* Demonstrates accuracy and attention to detail.* Demonstrated strong problem solving skills including the ability to handle difficult situations.* Ability to prioritize, organize and meet deadlines.* Excellent verbal and written communication skills.* Ability to work independently with minimal supervision.* Comfortable in both making decisions and acting.* Ability to multi-task and function effectively in a team environment and maintain effective relationships with coworkers, vendors and payers.* Advanced computer skills including in using Microsoft Office products, Adobe, electronic mail and/or electronic health information records systems and proficient keyboarding skills.* This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that may be requested in the performance of this job.* Employment is at-will. This document does not create an employment contract, implied or otherwise. #J-18808-Ljbffr