Claim Resolution Specialist II

GENERAL SUMMARY

The Claim Resolution Specialist II 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 II 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, 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.
• Manages claims processing independently or with minimal direction.
• Strong problem solving and decision making for claims resolution in accordance with established federal, state and insurance companies’ regulations.
• Advanced ability to prioritize and efficiently manage time.
• Performs other position related duties as assigned.
• Employees shall adhere to high standards of ethical conduct and will comply with and assist in complying with all applicable laws and regulations. This will include and not be limited to following the Solaris Health Code of Conduct and all Solaris Health and Affiliated Practice policies and procedures; maintaining the confidentiality of patients' protected health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA); immediately reporting any suspected concerns and/or violations to a supervisor and/or the Compliance Department; and the timely completion the Annual Compliance Training.

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 3 years billing or follow-up experience within a physician’s office or medical environment.
• Experience in Urology 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