Claims Resolution Specialist III Hybrid

Description

**This position is hybrid/remote if in the Chicago/Westchester area**

GENERAL SUMMARY

The Claim Resolution Specialist III focuses on following up and resolving claims submitted to third-party insurance payers. This includes claims that have yet to be adjudicated and denied accounts that require resolution. The Claim Resolution Specialist III is accountable for meeting or exceeding daily/weekly/monthly productivity targets set forth by management productivity policy and procedure standards. They work with the Business Office Supervisor to escalate claim and denial issues to resolve denials as efficiently as possible.

ESSENTIAL JOB FUNCTION/COMPETENCIES

• Responsibilities include but are not limited to:
• Conducts appropriate follow-up of no response third-party receivables in accordance with payer guidelines.
• Reviews and resolves claim denials, conducts follow-up, appeals processing, claim statusing and appeals template management when appropriate.
• Develops and maintains a working knowledge of payer contractual requirements particularly initial filing periods, appropriate follow-up and appeal protocols, and medical policies.
• Addresses/resolves issues relating to patient accounts while noting account actions for complete audit trail of follow-up activity.
• Drafts appeal letters as necessary.
• Communicates with Coders, Claim Readiness Specialist, and Business Office staff when necessary to resolve errors and clarify issues.
• Stays accountable to quality and productivity standards, and monitoring compliance with policies and procedures.
• Identifies process opportunity trends and recommend ways to improve efficiencies.
• Ensures adherence to third party and governmental regulations relating to coding, billing, documentation, compliance, and reimbursement.
• Participates in special projects, personal development training, and cross training as instructed.
• Informs Supervisor of trends, inconsistencies, and discrepancies for immediate resolution.
• Works in conjunction with peers and functional areas of the Business Office department for the betterment of completing tasks and the company overall.
• Navigates all systems (Allscripts PM, HST PM and HST Anesthesia). Knowledgeable in reporting within all systems.
• Trains new hires.
• Supports management in training and education to teammates.
• Performs other position related duties as assigned.

Requirements

CERTIFICATIONS, LICENSURES OR REGISTRY REQUIREMENTS

• N/A

KNOWLEDGE | SKILLS | ABILITIES

• Demonstrates understanding of business and how actions contribute to company performance.
• Knowledge of medical terminology, healthcare coding systems, and clinics functions.
• Experience in the use of CPT and HCPCS required.
• Efficiently reads explanation of benefits and understands denials.
• Develop and maintain a working knowledge of payer rules and guidelines.
• Ability to follow policies and procedures for compliance, medical billing, and coding.
• Ability to type and enter data with proficiency and accuracy.
• Proven ability to manage multiple projects at a time while paying strict attention to detail.
• Excellent organizational skills and attention to detail
• Customer-oriented with ability to remain calm in difficult situations.
• Strong analytical and problem-solving skills.
• Skill in using computer programs and applications including Microsoft Office.
• Ability to work independently and manage deadlines.
• Complies with all health and safety policies of the organization.
• Complies with HIPAA regulations for patient confidentiality.

EDUCATION REQUIREMENTS

• High School Diploma or equivalent required.

EXPERIENCE REQUIREMENTS

• Minimum 5 years' billing or follow-up experience within a physician’s office or medical environment required.
• Experience in Urology or physician practice environment preferred.

REQUIRED TRAVEL

• N/A

PHYSICAL DEMANDS

• Carrying Weight Frequency
• 1-25 lbs. Frequent from 34% to 66%
• 26-50 lbs. Occasionally from 2% to 33%
• Pushing/Pulling Frequency
• 1-25 lbs. Seldom, up to 2%
• 100 lbs. Seldom, up to 2%
• Lifting - Height, Weight Frequency
• Floor to Chest, 1 -25 lbs. Occasional: from 2% to 33%
• Floor to Chest, 26-50 lbs. Seldom: up to 2%
• Floor to Waist, 1-25 lbs. Occasional: from 2% to 33%
• Floor to Waist, 26-50 lbs. Seldom: up to 2%