Clm Resltion Rep III, Hosp/Prv - Remote/Hybrid Opportunity

Rochester Tech Park (RTP), Gates, NY - Remote options available after in-person training. Occasional onsite meetings / work at RTP are required. Remote location must be within 2 hours of RTP and within New York State.

Position Summary:

With latitude for initiative and independent judgment within department guidelines, the position is responsible for managing inpatient/outpatient accounts from the beginning of the billing period through the accurate resolution of the account. Revenue collection activities focus on an assigned payer billed at the primary level. Activities performed will focus on resolving balances on aged insurance accounts that have not been collected through routine billing and collection activities, ensuring the visit balances are set up on the accounts receivable at expected reimbursement, and determining and completing the collection process that will result in payment. Makes independent decisions as to the processes necessary to collect denied insurance claims and resolve billing issues. Maintain a detailed knowledge of billing requirements and regulations to ensure that the process conforms to federal and state regulations. The Claim Resolution Rep III will represent the department and Strong Memorial Hospital (SMH) in a professional manner, protecting the confidentiality of patient information at all times.

Supervision and Direction Exercised:

The Claim Resolution Rep III is responsible for self-monitoring performance on assigned tasks, following standard procedures and as directed by the Supervisor, Revenue Cycle Management.

Machines and Equipment Used:

Standard office equipment, including but not limited to: telephone, photocopy machine, adding machine, personal computer (for claims inquiry and entry software) fax/scanner, Flowcast billing application, Microsoft Word, Excel, Access, Email, Emdeon (Fidelis Medicaid Managed Care and Medicare Part B) clearinghouse software, third party claims systems (ePaces, Omnipro) and various payer web sites.

Typical Duties:

30% Complete follow-up activities on unpaid or under-paid accounts by contacting payer representatives or utilizing online systems with insurance companies and other third-party payers to obtain payments, research and resubmit rejected claims to primary payers, and obtain and verify insurance information.

• Follow up on unpaid accounts

• For unpaid accounts, check the claim status on the appropriate payer system or contact an insurance representative to obtain information as to why claims are not paid and the steps necessary for processing/payment

• Initiate collection phone calls to insurance companies to determine the reason for claim denial or the reason for unpaid claims. Address unpaid claims, and solicit a payment date from the payer.

- Research and calculate under or overpaid claims; determine final resolution- - - Re-calculate claim based on fee schedule, APC or APG grouper, appropriate % of charge, or ASC payment methodology, including add-ons

- - Follow-up with payers on incorrectly paid claims through final resolution and adjudication, including refund of credits

- - Review and advise supervisor or manager on trends of incorrectly paid claims from specific payers

- - Work with supervisor/manager on communication with payer representatives regarding payment trends and issues

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25% Work weekly, bi-weekly, and monthly reports and Work Lists via calculating and processing transactions such as payer-to-payer transfers, and contractual adjustments, and verify that the insurance levels and proration are set up correctly on the system.

• Examples of reports:

• 2nd level report

• Medicare and Medicaid credit balance report

• Over $10 k report

• Claim edits

20% Utilize a thorough knowledge of inpatient/outpatient billing policies and procedures for primary levels of third-party insurance; prepare log and related management reports when needed, price claims to establish the expected reimbursement on the revenue cycle system.

- - - - Initiate payer-related accounts receivable report to determine which visits need special attention and follow up to obtain correct full reimbursement

- - Billing primary and secondary claims to insurance

- - Review paper claims prior to billing. Review includes the potential of high cost, and late charges to facilitate any necessary manual keying into ancillary billing systems (ePaces, Emdeon, Omnipro, etc).

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20% Identify and clarify issues, payment variances, and/or trends that require management intervention; share with Supervisor and or Manager. Assist Supervisor with Medicare and Medicaid credit balance audits, and third-party payor audits

- Coordinate responses and resolution to Medicaid and Medicare credit balances- - - Review all accounts on the Medicaid and Medicare credit balance report:

- - Request insurance adjustments or retractions

- - Prepare requests for insurance and patient refunds

- - - - - - Enter Flowcast visit note documenting status or action taken.

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5% Research and respond to third-party correspondence, receive phone calls, and explain policies and procedures involving routine and non-routine situations. Assist other areas with patient-related questions. Communicate with other Hospital departments and with government and commercial insurance companies.

• Coordinate with other department within SMH to get claim issues resolved and complete audits.

Expectations:

• Participate in department staff meetings, education classes, and training

• Stay current on HIPAA guidelines through education and reading monthly emails

• Participate in URMC training such as Strong Commitment, ICare, and Annual Mandatory In-Service

• Join PFS committees such as Planning PFS events or addressing employee issues

Qualifications:

Requires: Associate's degree in Business Administration and 2 years of hospital patient accounting or consumer collections experience; or an equivalent combination of education and experience.

Note: This document describes typical duties and responsibilities and is not intended to limit managers from assigning other work as required.