Triage Order Quality Associate II

The Triage Order Quality Associate Level II (TOQII) position is responsible for the accurate and timely work of filing insurance claims for Abbott Cancer Diagnostics. This role will demonstrate medical insurance knowledge by determining initial and/or ongoing eligibility, coverage, and related insurance reimbursement order details, including commercial, government, and all various plan coverage. This role will identify order and reimbursement deficiencies, route orders for appropriate actioning and assist with triaging, and document actions taken within the systems for claims lifecycle tracking. This role will be responsible for claims escalations that TOQI are unable to resolve in addition to working “bulk” claim projects. This role will also support the broader activities of ensuring appropriate coverage by utilizing Epic, external portals, and other software, and communicate insurance information to ancillary departments and other teams within the reimbursement operations departments. 

Location: Remote, United States

Hours: 1st shift, business hours

• Independently determine initial or ongoing patient insurance eligibility verification; investigate and correct accounts within Epic, including updates to patient demographics, financial information, and guarantor information.
• Interact with various insurance companies and third-party payors accurately and timely to ensure authorization is obtained and documented based on internal and external policies and regulations.
• Research missing or erroneous information on accounts using various portals and other resources, including outreach and identification of unknown payors.
• Review and edit claims and appeals prior to submitting to the clearinghouse.
• Analyze, research, and resolve claim issues by applying federal, state, and payor rules and procedures with a high degree of independence.
• Monitor work queues (WQs) for claims requiring additional research and take appropriate action to move them toward resolution.
• Provide CRM support.
• Demonstrate an exceptional understanding of Claim Edit and Follow-Up WQs.
• Utilize OnBase to process documents specific to the TOQ department.
• Correct rejected claims from the claims scrubber, clearinghouse, or payor.
• Review explanations of payments, analyze denials, and complete appropriate resolution steps, including appealing, writing off, or sending statements.
• Validate new workflows resulting from product growth and maintain ownership of specific WQs until setup is validated and working effectively.
• Investigate payor underpayments.
• Follow up with payors via phone regarding unpaid and aging claims.
• Provide supporting documentation as needed by insurance payors.
• Perform accurate and timely write-offs after identifying uncollectible accounts, adhering to established policies and guidelines.
• Provide ad hoc support within the department as necessary, including special projects and support during outages or periods of high volume.
• Complete position responsibilities within appropriate timeframes while adhering to established quality standards.
• Stay current with relevant medical billing regulations, rules, and guidelines.
• Maintain the strictest confidentiality and adhere to all HIPAA guidelines and regulations.
• Demonstrate excellent problem-solving abilities and organizational skills.
• Communicate effectively with all levels of staff through both verbal and written communication.
• Work effectively in a team environment.
• Ability to adapt effectively to changing workloads and circumstances and respond quickly to new information.
• Disciplined, self-motivated, and reliable.
• Ability to stay focused on tasks and work independently while remaining motivated to produce quality work.
• Diligent about arriving to work on time and completing assigned tasks within established timeframes.
• Conduct oneself professionally in all interactions with members of the Exact Sciences Clinical Laboratory team, clients, and associates.
• Possess a positive attitude.
• Work collaboratively with others in a spirit of teamwork and cooperation.
• Uphold the company’s mission and values through accountability, innovation, integrity, quality, and teamwork.
• Support and comply with the company’s Quality Management System policies and procedures.
• Maintain regular and reliable attendance.
• Ability to work a normal Monday through Friday schedule during standard business hours.
• Ability to work in front of a computer screen and/or perform typing for approximately 90% of a typical working day.
• Ability to work on a computer and phone simultaneously.
• Ability to use a telephone with a headset.
• Successfully complete an assessment demonstrating an understanding of Exact Sciences Epic processes necessary for the job functions with a score of 80% or higher. Exact Sciences will make reasonable accommodations available, if necessary, to assist an employee with a disability in satisfying this requirement.

• High School Diploma or General Education Degree (GED).
• 1+ years of experience in the role of TOQ Associate Level I.
• 3+ years of experience in medical billing, claims, and/or insurance processing.
• Extensive and current working knowledge of government, managed care, and commercial insurance claim submission requirements, reimbursement guidelines, and denial reason codes.
• Knowledge of medical terminology and/or health insurance terminology.
• Knowledge of EHR operating systems and experience working with electronic records.
• Proficiency with computer systems and keyboarding.
• Demonstrated strong attention to detail and focus on quality output.
• Demonstrated ability to perform the essential duties of the position with or without accommodation.
• Authorization to work in the United States without sponsorship.

• Related Associate degree or medical billing certification.
• 5+ years of experience in the medical or insurance billing field.
• Experience with Epic or another EHR application.

In specific locations, the pay range may vary from the range posted.