Claims Resolution Specialists II

Review medical insurance claims for resolution and to obtain appropriate payment thru outlined processes. Resolve incoming inquiries, denials and correspondence from various entities to obtain appropriate resolution and payment in timely manner.  Contact insurance carriers to research, compile and respond on open account balances to obtain appropriate payments. 

High School diploma or GED required.  At least 1 year of prior work experience in the medical field, as well as experience in medical billing and/or collections. Must have excellent knowledge of insurance carrier billing and reimbursement with knowledge of medical terminology, ICD-9, ICD-10 and CPT codes. Must have an in-depth understanding of explanation of benefits (EOB).  Electronic Medical Records (EMR), GE Centricity Practice Management software experience preferred. Employee must be knowledgeable in Medical Oncology/Hematology and/or Radiation, Pathology, Radiology, Pumps and Specialties.  Excellent communication and interpersonal skills are required. Employee must be able to work independently as well as in a team. Employee must complete 6 CEUs annually.

Apply billing/collection knowledge required for insurance payers to insure proper and maximum reimbursement.

Respond to patient and office inquiries regarding outstanding insurance balances, insurance payments received, allowable charges, assignment of benefits and any other insurance questions.

Manage insurance review and denial of payment by responding with appropriate documentation to support appeal.  Follow-up on claim to ensure payment was received.  Coordinate effort with office personnel and/or the doctor as necessary. 

Report any consistent claim denials or problems to appropriate team lead per payer. 

Inquire about and resolve any payments that differ from established profile on our payer contracts. 

Attend third party payer meetings, seminars, and training sessions and report any changes or concerns to your supervisor.

Follow-up on correspondence in a timely manner.

Transfer appropriate balances to patient responsibility per SOP and notify the patient and appropriate department of this action accordingly. 

Bill applicable secondary insurance.

Document all collection activity in Onco EMR, Centricity and Unity.

Contact patients to correct insurance information to ensure accuracy as needed.

Maintain and ensure the confidentiality of all patient and employee information at all times as established by HIPPA and Company policies.

Keep work area and records in a neat and orderly manner.

Maintain all company equipment in a safe and working order.

Will be expected to work at any Company location to help meet the Company’s business needs.  

 Must establish and maintain effective work relationships with new and existing customers through a high degree of professionalism and excellent interpersonal communication skills.

Will be expected to complete additional reports or projects as assigned by management.

Comply with all Federal and State laws and regulations pertaining to patient care, patients’ rights, safety, billing, human resources and collections. Adhere to all Company and departmental policies and procedures, including IT policies and procedures and Disaster Recovery Plan. 

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