Account Resolution Rep II PB

Children's Wisconsin•West Allis, WI

About The Position

The Account Resolution Rep II researches and resolves complex Professional Billing service insurance denials for Children’s Wisconsin, seeking maximum reimbursement from third-party payers, state programs, and contracted organizations. The role follows up on assigned accounts, investigates denials and reimbursement issues, and works with patients, guarantors, payers, leadership, and coding staff to resolve billing matters. It also maintains knowledge of payer contracts, billing policies, and department procedures while meeting management-set productivity and quality standards.

Requirements

High school graduate, GED, or HSED.
At least 2 years of experience in claims follow-up in healthcare revenue cycle operations, including reimbursement procedures and understanding insurance EOBs.
Working knowledge of medical terminology and ICD-10, CPT, and HCPCS Level II codes.
Strong understanding of payer guidelines, policies, and procedures.
Excellent verbal and written communication skills.
Ability to work independently with minimal supervision.
Strong analytical skills and ability to perform noncomplex arithmetic calculations when determining contractual allowances.
Working knowledge of account reconciliation and third-party reimbursements from commercial, Medicaid, and Medicare carriers.
Interpersonal skills to respond effectively to questions from patients, parents, clinic staff, and insurance companies and resolve billing issues.
Ability to multitask, work effectively in a team environment, and maintain effective relationships with coworkers, patients, physicians, management, staff, and other customers.
Proficiency in Microsoft Office applications and technology skills needed to perform the duties.

Nice To Haves

Prior experience in a hospital system working with professional billing claims and functions.
Inpatient and surgical medical billing experience.
Mental and behavioral health billing experience.
Experience in Epic Resolute.

Responsibilities

Contact guarantors and insurance companies, update registration, correct and resubmit claims, and file appeals to resolve claims.
Maintain current knowledge of managed care payer contracts and third-party payer billing guidelines and policies for assigned commercial and government payers.
Follow up on assigned work queues to ensure reimbursement within payer timely-filing guidelines.
Identify CPT-4, ICD-10, and modifier-related coding issues and collaborate with leadership and the coding team to resolve them.
Investigate complex insurance denials, identify or track payer-related trends, and inform leads and management of issues affecting reimbursement.
Submit written and online correspondence and appeals to payers to obtain appropriate payment.
Review claims and recommend adjustments to management; apply account adjustments when appropriate.
Use payer websites to verify patient insurance information and claim status, payments, and denials, and to submit online appeals as needed.
Maintain understanding of accounts receivable functions and department policies and procedures.
Meet productivity and quality standards established by management.