University of Rochester · 3 months ago
Claim Resolution Rep IV
Gates, NY
Full-time
Hybrid
Mid Level
$20.99/hr - $28.34/hr
3+ years expThe University of Rochester is committed to fostering an inclusive community and is seeking a Claim Resolution Rep IV. This role involves managing and resolving complex claims, mentoring staff, and ensuring maximum revenue collection through effective follow-up and problem-solving techniques.
Health CareMedicalUniversities
Responsibilities
Independently determines the most effective method to follow up on disputed, unpaid, underpaid, or overpaid insurance or contracted service accounts in order to bring about prompt account resolution and revenue collection from complex claims, high dollar claims, and specialized services
Identifies and resolves problems related to primary and secondary accounts which are disputed, unpaid, underpaid or overpaid
Determines cause of problem and initiatives corrective action through reviews of electronic medical records
Works to confer with external agencies
Analyzes accounts and determines if correct proration of revenue has been collected, using detailed understanding and application of all payer contracts
Contacts applicable agency, payer or department for resolution
Decides when resubmitting efforts are complete, including writing an appeal using applicable content and supporting documentation to appropriately influence the highest level of revenue
Acts as a resource for questions from assigned collection and billing staff on payer policies, procedures and methods of revenue collection
Trains new staff on the use of the billing application, payer systems, and clearinghouse systems
Demonstrates how to apply the knowledge of payer contracts and resources to resolve disputed, unpaid, underpaid, or overpaid accounts
Provides feedback to leadership on results of training of new and existing staff
Provides input for performance assessments based on observation, questions, and quality reviews of work performed
Acts as area leader, when needed, including responding to payers, patients, and issues referred to the area from hospital departments or department representatives
Researches and responds to clinical department inquiries on complex, high dollar, and specialized accounts and status of collection activities affecting departmental revenue
Assesses if/when patients are contacted
Resolves complex, high dollar, and specialized claim resolution issues due to coordination of benefits, eligibility issues, and authorizations
Resolves accounts identified in third party audits involving retroactive approvals, resulting in adjustments, refunds, and subsequent secondary billing
Researches, verifies, and/or obtains authorizations post-claim submittal
Determines allocation of reimbursement applicable to multiple providers for global transplant payments and initiates transfer of money to each payer
Identifies need for in-person meetings and phone conferences with third party insurance representatives due to claim and system issues requiring prompt attention for complex high dollar accounts
Prepares information for and attends meeting with third-party insurance representatives on claims and systems issues for scheduled in-person meetings and phone conferences regarding complex high dollar claims
Identifies and clarifies issues that require management and intervention to avoid loss of revenue
Recommends filing of a formal complaint with the State’s regulation commission or agency
Determines when to change the account to a self-pay financial class after a review of previous efforts has not resulted in revenue collection and further attempts would not be successful without patient intervention
Research and initiates suggestions to leadership to streamline processes and training materials
Performs coverage for other positions as needed
Performs administrative office tasks and maintains records
Qualification
Required
Associate's degree and 3 years of relevant experience required
Or equivalent combination of education and experience
Company
University of Rochester
The University of Rochester is a private research university located in Rochester, New York.
10001+ employees
H1B Sponsorship
University of Rochester has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (234)
2024 (126)
2023 (130)
2022 (106)
2021 (100)
2020 (92)
Funding
Current Stage
Late StageTotal Funding
$20.43MKey Investors
National Science FoundationUnitedHealthcareSociety to Improve Diagnosis in Medicine
2023-09-25Grant· $18M
2023-07-26Grant· $0.07M
2022-09-20Grant· $0.05M
Leadership Team
David Linehan
Chief Executive Officer
Recent News
2025-12-04
Company data provided by crunchbase