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Austin Regional Clinic: ARC · 16 hours ago

Claims Resolution Specialist (Hybrid)

Austin, TX

Full-time

Hybrid

Entry, Mid Level

2+ years exp

Austin Regional Clinic is one of central Texas’ largest professional medical groups, recognized as a top employer for over 15 years. The Claims Resolution Specialist is responsible for processing follow-up actions on denied claims and ensuring compliance while promoting the organization's mission.

Health CareMedical

Responsibilities

Takes appropriate follow up action on denied claims based on the ANSI Reason Code, payer policy, eligibility and so forth. Either prepares appeals, performs write off actions or assigns financial responsibility to next party in accordance with company policy

Uses Epic In-Basket messages to communicate with appropriate staff to obtain authorization to edit claim data and other assistance with follow up and/or appeal actions

Reviews procedure and diagnosis codes to make sure they conform to third party rules and ensure appropriate reimbursement

Researches insurance payments and ANSI reason code denials to determine correct posting information

Edits claims through Correct/Report actions to reflect complete, accurate & updated information

Processes and submits appeals in accordance with payer policy

Maintains and follows up on accounts appropriately and clearly and accurately documents issues, sources and actions taken to describe activities and results in Account Contact

Reviews accounts for credits and requests refunds to insurance companies or patients as necessary

Submits EOB and other supporting documentation to the Supervisor and Team lead for approval to adjust any charges that exceed the approved threshold

Informs and works with management team when all usual attempts to collect from third parties and/or customers have failed to result in adequate reimbursement

Follows up with insurance carriers on problematic coverage issues

Follows up with insurance carriers on problem payments and adjustments

Utilizes payer and clearinghouse web-sites for claims status or eligibility

Completes assigned department problem tickets

Opens a weekly system batch to store correspondence & other documents; references batch number in account notes to cross reference document location

Opens, closes, and process batches according to departmental guidelines

Generates any adjustments necessary to complete posting of payments

Uses appropriate Epic Functions, write off codes and ANSI Remark codes when performing actions through Account Maintenance

Adds a termination date to patient coverage when claim is denied “coverage termed.”

Reviews and follows up on Patient Account Teams’ inquiries according to established policy

Documents daily work/ tasks on weekly Excel pivot table

Identifies and documents new payer denial trends, and notifies supervisor for escalated follow up

Escalates unresolved claim denials to supervisor for follow up with health plan provider representatives

Performs all duties within established departmental time frames

Regular and dependable attendance

Attends required in-service / training sessions. Adheres to all company policies, including but not limited to, OSHA, HIPAA, compliance and Code of Conduct

Follows the core competencies set forth by the Company, which are available for review on CMSweb

Thoroughly researches reasons for denied claims in assigned work queues to resolve outstanding balances

Acts upon payer correspondence in a timely manner to avoid posted deadlines

Utilizes the work queue activity to track follow up activities

Manages follow-up work queues as assigned using tools and resources provided by leadership

Places account notes in the account to document all activities and results

Maintains correspondence per department standard

Posts zero payment EOBs / correspondence using a Payment Posting Batch

Reviews work queue summary for each correspondence account and completes from work queues as appropriate

Respond to Patient/Customer to confirm receipt of / or provide resolution to written correspondence

Forwards requests for Registration verification and updates to the Registration Team

Provides back up to Customer Service and assistance to the Central Registration call center

Meets job standards for Patient Registration and Posting positions

Keeps complete, accessible and dated files

Verifies insurance eligibility and sets up accounts by account type classifications

Provides workload statistic reports to management team

Assists in training other staff members

Provides assistance to coworkers as requested and/or necessary

Performs other duties as assigned

Qualification

Claim denial managementMedicareMedicaid knowledgeProceduralDiagnostic codingEpicBilingual in SpanishEnglishComputer skillsManage prioritiesMicrosoft OfficeAdobeCommunication skills

Required

High school diploma or GED

Experience using computer data processing systems

Two (2) or more years of experience working claim denials for either professional or hospital billing

Knowledge of and/or experience with Medicare, Medicaid and commercial insurance plan registration, and eligibility verification

Knowledge of and/or experience with procedural and diagnostic coding

Knowledge of ANSI codes

Knowledge of claim denial management

Knowledge of patient copay vs. cost share responsibility

Ability to engage others, listen and adapt response to meet others' needs

Ability to align own actions with those of other team members committed to common goals

Excellent computer and keyboarding skills, including familiarity with Windows

Excellent verbal and written communication skills

Ability to interpret payer explanation of benefits

Ability to manage competing priorities

Ability to perform job duties in a professional manner at all times

Ability to understand, recall, and apply oral and/or written instructions or other information

Ability to organize thoughts and ideas into understandable terminology

Ability to apply common sense in performing job

Experience with Microsoft Office

Experience with Adobe

Preferred

At least two (2) years of customer service experience

Bilingual in both Spanish and English

Experience with Epic

Benefits

Medical

Dental

Vision

Flexible Spending Accounts

PTO

401(k)

EAP

Life Insurance

Long Term Disability

Tuition Reimbursement

Child Care Assistance

Health & Fitness

Sick Child Care Assistance

Development

Company

Austin Regional Clinic: ARC

Austin Regional Clinic (ARC) is a multispecialty medical group committed to providing comprehensive, coordinated healthcare services throughout Central Texas.

Founded in 1980

Austin, Texas, USA

1001-5000 employees