Responsibilities

Location:

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:

The Claim Resolution Rep II is responsible for the accurate and timely preparation and submission of third-party billing/claims to governmental or third-party payers. Re-submits claims that fail third party edits and submits second level claims. Provides guidance and support to Billing Assistant and answers correspondence. The Claim Resolution Rep II will represent the department and Strong Memorial Hospital (SMH) in a professional manner, protecting confidentiality of patient information at all times.

Supervision and Direction Exercised:

Responsible for monitoring own performance on assigned tasks against procedure standards. May train and coordinate activities of peers as directed by Supervisor, Revenue Cycle Management and Manager.

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

35% Researches and corrects primary payer claims that have failed to process.

• Using knowledge of payer billing software makes corrections directly in payer system.

• Identifies non-routine problems for claims requiring correction and decides action for correction by reviewing bill types and interpreting visit notes.

• Resolves non-routine upfront edits on Emdeon which include but are not limited to modifier requirements or provider enrollment issues. Identifies claims that require further research and determines source of correction and initiates request through PAO supervisors or appropriate clinical department. Tracks pending claims and makes appropriate correction once answer has been received.

• Notifies the team Supervisor, Revenue Cycle Management when the amount of edits holding exceeds normal target ranges. Prepares written summary of the issues regarding the edits.

• Documents all actions thoroughly in visit notes.

30% Submits secondary payer claims.

• Prepares paper claims for secondary submission using knowledge of secondary payer unique requirements and processes. Provides primary payment information and determines adjustment information and applicable details required for each claim.

• Determines when a “no-pay” claim request must be submitted to a primary payer in order to obtain a denial sufficient to be sent to the secondary payer. Reviews claim data and modifiers as well as secondary payer and patient requests prior for appropriateness of secondary payer submission.

• Compares primary payment to the anticipated secondary payment to determine whether or not to follow secondary payer submission process. Using knowledge of payer rules submits secondary bills after confirming that an additional payment is due.

• Resolves non-routine upfront edits on Emdeon which include but are not limited to modifier requirements or provider enrollment issues. Identifies claims that require further research and determines source of correction and initiates request through PAO supervisors or appropriate clinical department. Tracks pending claims and makes appropriate correction once answer has been received.

• Documents all actions thoroughly in visit notes.

30% Corrects claim errors returned post-submission.

• Reviews claims requiring non-routine correction in payer system to determine method of correction.

• Adjusts claims through manual process to ensure highest level of reimbursement. Determines cause of error to identify appropriate source that can supply applicable missing information (e.g. modifiers, medically unlikely edits). Tracks pending claims and makes appropriate correction once answer has been received.

• Identifies the correction method needed when additional modification of a claim triggers an additional edit. Finalizes claim submission following resolution.

10% Other duties as assigned:

• Provides guidance and support to Billing Assistants

• Manually keys/ enters late charges on 141 bills in Omnipro

• Answers correspondence

Expectations:

• Participate in department/team staff meetings, educational classes and training

• Attend monthly department and team staff meetings

• Stay up to date on HIPAA guidelines through education and reading monthly emails

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

• Join PAO committees such as planning PAO events or addressing employee issues

• Attend weekly meetings

Qualifications:

Requires: Associate's degree in Accounting and 1 year of related accounting or collection experience; or an equivalent combination of education and experience.

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

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $18.52 - $25.01 Hourly

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job’s compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

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Location: Strong Memorial Hospital
Full/Part Time: Full-Time
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