Claims Resolution Specialist

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.

• At least 3 to 5 years of general liability claims management experience required; commercial lines experience strongly preferred
• Familiarity with coverage, negligence principles, investigation and negotiation techniques
• Strong organizational skills and detail orientation • Ability to work independently, handle multiple tasks simultaneously and exercise good judgment
• Excellent verbal and written communication skills • Computer literacy, including working knowledge of MS Office including Word, Excel and PowerPoint
• Work a minimum of 65 accounts a day
• Key Responsibilities Process escalated claims, assess reasons for escalation, and provide resolutions in priority order as directed
• Use systems, reports, and Standard Operating Procedures to work assigned claim steps and gather supporting information
• Communicate regularly with clients and customers, offering value-add solutions and proactively managing target dates to ensure timely claim processing