Position Summary:

Ensure full reimbursement is received by RRH for clinical services rendered including professional, long-term/home care and hospital care, by effectively and accurately managing a receivable. Resolve edits to ensure accurate claims are sent to primary and secondary insurances. Research and resolve denials and payer requests for information promptly and accurately in order to secure payment. Work as part of a dynamic team continually looking for ways to improve a complex business process.

Key Responsibilities:

• Review and accurately process claim edits in a system workqueue. Accurately handle claim adjustments and coverage changes as needed.

• Review and process claim denials according to established processes. Research and resolve denial issues via the payer website, coverage policies and/or phone calls to the payer. Submit corrected claims and appeals.

• Process account adjustments and refunds as needed according to department policy and procedure.

• Document actions appropriately and follow-up with payers to ensure they take actions promised. Follow-up on claims with no responses. Manage large workload using tracking tools to ensure we don’t fail to follow-up before a payer’s deadline.

• Participate in team meetings which review new procedures, new denial types and system updates. Report problems and patterns to the supervisor to help keep policies and procedures up to date with new clinical programs and payer policy changes.

• Acquire and maintain knowledge of system terminology, claim/denial/coverage concepts and terms, and relevant HIPAA privacy rules and other regulations. Expertly use insurance websites to explore denial issues and resolve them using the tools in Epic, including accessing clinical documentation and authorization details.

• Respond to patient complaints by researching coverage and claim processing to ensure the patient responsibility is accurate. Contact insurance as needed. Coordinate resolution with Customer Service staff.

For Revenue Integrity:

• For team members who are responsible for completing payment posting: research and resolve payment posting requests/discrepancies in order to properly relieve the receivable

• Review and accurately scan/index remittances and correspondence

• Identify and accurately post remittances for all payors to correct accounts/systems according to department policy and procedure

• Expertly use insurance websites to explore denial and payment issues and resolve them using the tools in Epic, including accessing clinical documentation and authorization details

Desired Attributes:

i. Education/Training: At least one year experience in a Medical Office environment preferred
ii. Basic knowledge of medical billing, cording, collection processes, insurance policies and governmental regulation provision preferred
iii. Knowledge of UBO4 billing form and 1500F05 specific payer requirements preferred
iv. Excellent problem solving, organizational and oral and written communication skills required
v. Successful completion of annual age and job specific competencies and skill verification tools required
vi. Proficiency in a variety of computer applications and spreadsheet applications and common office equipment

Minimum Qualifications:

• None

Required Licensure/Certification Skills:

• None ​

Rochester General Health System is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran