Payment Resolution Analyst

Responsible for researching and resolving all Professional Billing overpaid and underpaid balances. This role will also be responsible for reviewing insurance underpayments to ensure claims are paid at maximum reimbursement from third party payers, state programs and contracted organizations for Children's Wisconsin and Children's Specialty Group. This role is also responsible for following-up on customer inquiries related to overpayments and underpayments.

Responsibilities

Research and resolve all Professional Billing overpaid and underpaid balances; Review insurance underpayments to ensure claims are paid at maximum reimbursement from third party payers, state programs and contracted organizations; Follow up on customer inquiries related to overpayments and underpayments; Investigate credit balances, including research of EOB's and verification of accurate contractual discounts; Review written requests for refunds from insurance companies and other payers and complete appropriate paperwork for management authorization; Maintain knowledge of primary care and complex specialty billing guidelines for Professional Billing; Collaborate with Payer Contracting team and maintain current knowledge of managed care payer contracts and third-party payer billing/reimbursement policies; Identify coding issues relating to CPT-4 and ICD-10 and use of appropriate modifiers that resulted in overpayments/underpayments; Collaborate with leadership and coding team on resolution; Utilize payer websites to verify patient insurance information, claim status/payments/denials/appeals; Analyze and investigate improper insurance credits and identify/track trends associated with payers; Submit written and online correspondences and appeals to payers when disputing a refund/recoup request; Maintain productivity and quality standards as set by management

Requirements

High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED); 2+ years of experience in professional billing and follow up; Working knowledge of medical terminology, ICD-10 and CPT; Excellent verbal and written communication skills; Ability to work independently with minimal supervision; Interpersonal skills necessary to respond to questions from patients, parents, clinic staff and insurance companies; Proficient in Microsoft Office applications; Ability to multi-task and function effectively in a team environment

Nice to have

Pediatric experience; Prior experience in a large health system working with professional billing claims and functions; Medical billing experience; Prior credit resolution/payment posting experience; Experience in Epic Resolute