Payment Resolution Analyst

Professional Billing Specialist

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.

Essential Functions

• Investigate credit balances to include research of EOB's and verification of accurate contractual discounts. Reviews written requests for refunds from insurance companies and other payers to protect CHW's financial interests and completes appropriate paperwork for management authorization.
• Maintains knowledge of primary care and complex specialty billing guidelines pertaining to each provider group for Professional Billing.
• Collaborates with Payer Contracting team and maintains current knowledge of managed care payer contracts and third-party payer billing / reimbursement policies for Professional Billing along with all lines of business (Government, HMO and Commercial).
• Identifies coding issues relating to CPT-4 and ICD-10 and use of appropriate modifiers that resulted in overpayments / underpayments balances. Collaborates with leadership and coding team on resolution.
• Utilizes payer websites to verify patient insurance information, claim status / payments / denials / appeals as necessary.
• Analyzes and investigates improper insurance credits, identify and / or track trends associated to payers. Keeping leads and management appraised of identified issues having an impact on reimbursement.
• Works with Lead and Manager to resolve claim / credit issues.
• Submits written and online correspondences and appeals to payers when disputing a refund / recoup request as needed to obtain maximum reimbursement.
• Maintains productivity and quality standards as set by management.

Education : High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED) or Certificate of General Educational Development (GED) required

Experience : 2+ years of experience in professional billing and follow up required Pediatric experience preferred Prior experience in a large health system working with professional billing claims and functions preferred Medical billing experience preferred Prior credit resolution / payment posting experience preferred Experience in Epic Resolute preferred

Knowledge, Skills and Abilities 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 efficiently respond to questions from patients, parents, clinic staff and insurance companies to effectively resolve billing issues. Proficient in Microsoft Office applications and technology skills required to perform duties. The ability to multi-task and function effectively in a team environment and maintain effective relationships with coworkers, patients, physicians, management, staff and other customers.

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.

Fully Remote Work Opportunity

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.