Claims Resolution Specialist

Department:  Billing

Position:  Claims Resolution Specialist

Employee Category:  Non-Exempt

Reporting Relationship:  Manager of Revenue Cycle Management

Character First qualities:

• Decisiveness- The ability to recognize key factors and finalize difficult decisions.
• Dependability- Fulfilling what I consented to do, even if it means unexpected sacrifice
• Initiative – Recognizing and doing what needs to be done before I am asked to do it.
• Thoroughness – Knowing what factors will diminish the effectiveness of my work or words, if neglected.
• Flexibility – Willingness to change plans or ideas without getting upset.

Summary of Duties and Responsibilities:

The Claims Resolution Specialist is responsible for resolving all issues in with unpaid insurance claims  in a timely manner by researching all incoming denials from insurance companies, initiating the collection process through contact with the payer, researching payer and government websites and/or medical resources to identify claim requirements required to resolve open accounts receivable and works to minimize write-offs by exhausting  in all resolution options. The Claims Resolution Specialist also leverages technology and identify and report process inefficiencies and make recommendations for continuous improvement and opportunities that will enhance revenue flow.

Primary Duties and Responsibilities:

1. Proactively monitors the clearinghouse to resolve issues and errors in a timely manner.
2. Continuously evaluates and works A/R balances to prevent timely filing and loss of revenue from denials and missed opportunities on secondary filings.
3. Identifies claim denial reasons, eligibility discrepancies and billing errors and resolve them in a timely fashion to ensure prompt payment of claims.
4. Makes inquiries and follow-up on all denied and unpaid insurance claims to include Medicare, Medicaid and third-party insurances.
5. Accurately and efficiently processes requests for denied claims information using website portals and outbound phone calls for all payers.
6. Resolves edits related to coding; obtain and review required documentation to support services billed.
7. Researches and locate missing payments and/or remittance advice forms.
8. Reviews and obtains appropriate documentation for claim re-submission per insurance guidelines and requirements.
9. Contacts patients and/or referrals for missing information or documentation.
10. Tracks and maintains follow-up documentation of claim re-submissions.
11. Documents all communication with co-workers, patients and payer sources in patient’s account in electronic health record.
12. Oversees insurance correspondences, research and perform appropriate steps for first and second appeals.
13. Works with insurance payors to ensure timely and accurate payments.
14. Communicates with insurance carriers to track status of appeals.
15. Tracks improvement of targeted denials once processed, or when system edits have been developed to reduce/prevent future denials.
16. Troubleshoots patient account issues including direct resolution of billing issue with patients. Ensure accurate patient statements are sent out monthly along with analyzing patients accounts and make recommendations to collections accordingly.
17. Tracks and reports ongoing issues and trends to the Manager of Revenue Cycle Management.
18. Meet established daily, weekly, monthly and annual deadlines
19. Manage and maintain relationships with all payors to improve patient revenue.
20. Uphold Medicare, Medicaid, and HIPAA compliance guidelines in relation to billing, collections, and PHI information.
21. Follow written and verbal instructions from the Manager of Revenue Cycle Management.
22. Exhibit professionalism in communication with patients, clients, insurance companies and co-workers.
23. Participate in special projects.
24. Support Variety Care’s accreditation as a Patient-Centered Medical Home and our commitment to provide care to all Variety patients that is Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable. Provide leadership and work with all staff to achieve the goals of the “Triple Aim” of healthcare reform—to improve the experience of care, improve health outcomes, and decrease healthcare costs.
25. Embodies the strength of personal character. Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment.  Must be a leader in the department and community.  Result-oriented problem solver who is responsible and accountable.
26. Other duties as assigned.

Requirements, Special Skills or Knowledge:

1. High School Diploma or GED required. Associate's degree highly preferred or equivalent combination of experience and education.
2. Three to five years medical billing experience required.
3. Prior medical billing and insurance collections or healthcare revenue cycle experience including diversified experience with payers, managed care contracts, and payer methodology is required.
4. Working knowledge of CPT codes.
5. Understanding of medical terminology and protocols as well as basic knowledge of coding and anatomy are required.
6. Demonstrated mastery of critical thinking, analytics, problem-solving and sound decision-making skills required.
7. Demonstrated ability to interact and communicate effectively with individuals at various levels both inside and outside the organization, often in sensitive situations.
8. Proficiency and clerical accuracy with Microsoft Office and practice management software systems.
9. Professionalism, integrity, responsibility and dependability.
10. Strong attention to detail, negotiation and problem-solving skills.
11. Ability to assist and support others in a professional and respectful manner.  

ADA Requirements:  

1. Must be able to lift and/or move up to 25 pounds.
2. While performing the duties of this job, the employee is frequently required to sit, stand, walk and talk.
3. Frequently required to bend and reach to fulfill job duties.