Account Resolution Representative

Account Resolution Representative

At Children's Wisconsin, we believe kids deserve the best.

Children's Wisconsin is a nationally recognized health system dedicated solely to the health and well-being of children. We provide primary care, specialty care, urgent care, emergency care, community health services, foster and adoption services, child and family counseling, child advocacy services and family resource centers. Our reputation draws patients and families from around the country.

We offer a wide variety of rewarding career opportunities and are seeking individuals dedicated to helping us achieve our vision of the healthiest kids in the country. If you want to work for an organization that makes a difference for children and families, and encourages you to be at your best every day, please apply today.

Job Summary The Account Resolution Representative is responsible for obtaining fiscal resolution of Government, Medicaid HMO, and Commercial insurance claims. Fiscal resolution is accomplished through following governmental regulations and guidelines & commercial insurance contractual agreements to ensure facility is receiving proper payment for services rendered. The Account Resolution Representative is responsible for investigation of claims denials, insurance processing errors, & open no response claims; in addition to verification accounts are with the correct payer liability and balance. The role also requires follow up on previously actioned on denials, escalation of stalled claims, and identification of payer specific trends to escalate with the Hospital Billing leadership team. Essential Functions

• Utilizes Hospital computer billing system(s) (Epic) to follow-up on unpaid, underpaid, and credit balance claims ensuring timely filing guidelines are followed.
• Verifies accounts are with the correct payer liability and balance with the payer by utilizing payer websites and electronic eligibility clearinghouses to verify the accuracy of the patient insurance information. Ensures timely claim submission(s).
• Performs comprehensive collection actions including contacting patients/parents, insurance companies, correcting and resubmitting claims. Documents activities in the appropriate system.
• Responsible for responding to and resolving claim denials by filing appeals in accordance with individual payer requirements.
• Identifies and escalates denials to RN Auditors per applicable departmental policies and procedures.
• Analyzes payer errors and/or denials to identify trends. Escalates trends and high volume issues to Lead and Management to lessen impact on Cash flow.
• Validates and facilitates release of information (ROI) requests for patient medical records from external requestors (insurance payers and third-party vendors) in a timely and efficient manner. Partners with Release of Information team and vendor to ensure deadlines related to release of information are met to avoid denials and financial risks to Children's Wisconsin. Ensures accuracy and quality of the medical records processed and released.
• Investigates credit balances to include research of EOB's and verification of accurate contractual discounts. Review written requests for refunds from insurance companies and other payers to protect CHW's financial interests and completes appropriate paperwork for management authorization.
• Maintains current knowledge of all payer contracts and third party payer billing/ reimbursement policies for all lines of business (Government, HMO and Commercial).
• Reviews and enters adjustment requests as appropriate using departmental specific adjustment codes.

Legacy Essential Functions

• Works with Lead to resolve complex claims issues using all available departmental resources.
• Complies with productivity standards while maintaining quality levels. Documents all work in accordance with departmental standards.
• Responsible for understanding and adhering to the Children's Organizational Code of Ethics and for ensuring that personal actions comply with the policies, regulations and laws applicable to Children's business.
• Utilizes appropriate tools and resources to assist in the processing and follow up of claims, such as Adobe, RightFax and payer and vendor websites.

Education:

• High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED) Required
• Associate's Degree or higher in Medical Billing and Coding, in Health information Management, Healthcare Services Management, Health Information Technology Preferred or
• Associate's Degree in a business related field Preferred

Experience:

• 2+ years experience in claims follow up, HCFAs and/or UB-04's (preferably in a hospital setting) including insurance reimbursement procedures and comprehension of insurance EOB's Required
• General pediatric and/or pediatric subspecialty experience Preferred
• Prior Epic experience Preferred

Knowledge, Skills and Abilities:

• Basic knowledge of medical records and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Basic knowledge and understanding of medical terminology and human anatomy and disease processes.
• Basic knowledge of ICD-10, CPT and HCPCS level II codes.
• Demonstrates accuracy and attention to detail.
• Demonstrated strong problem solving skills including the ability to handle difficult situations.
• Ability to prioritize, organize and meet deadlines.
• Excellent verbal and written communication skills.
• Ability to work independently with minimal supervision.
• Comfortable in both making decisions and acting.
• Ability to multi-task and function effectively in a team environment and maintain effective relationships with coworkers, vendors and payers.
• Advanced computer skills including in using Microsoft Office products, Adobe, electronic mail and/or electronic health information records systems and proficient keyboarding skills.

Required for All Jobs:

• This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that may be requested in the performance of this job.
• Employment is at-will. This document does not create an employment contract, implied or otherwise.

• Remote Position!
• Flexible schedule
• Epic preferred
• 2+ years in claims follow‑up with HCFAs/UB‑04s and insurance reimbursement/EOB comprehension required
• Pediatric or pediatric subspecialty experience preferred
• Prior Epic experience preferred

Children's Wisconsin is an equal opportunity / affirmative action employer. We are committed to creating a diverse and inclusive environment for all employees. We treat everyone with dignity, respect, and fairness. We do not discriminate against any person on the basis of race, color, religion, sex, gender, gender identity and/or expression, sexual orientation, national origin, age, disability, veteran status, or any other status or condition protected by the law.

Certifications/Licenses: