Claims Resolution Representative II, Hospital/Professional

The Claims Resolution Representative II is responsible for working across the professional fee organization and performing routine follow-up activities to bring open accounts receivable to successful closure. The role focuses on effective claims follow-up to maximize revenue collection, including researching, correcting, resubmitting claims, submitting appeals, and taking timely action to resolve unpaid claims.

With general direction from the manager, supervisor, or lead, the position:

• Follows department policies and procedures and applies knowledge of insurance billing requirements and regulations to research and resolve unpaid accounts receivable.
• Reviews denied accounts using remittances (EOBs), insurance correspondence, and electronic claim rejections, then researches issues and takes appropriate action for resolution.
• Responds to billing-related inquiries from colleagues, departments, patients, and payors in a timely and professional manner.
• Communicates missing or incomplete information to providers and administrative support staff to support accurate billing.
• Works with insurance representatives through phone, payer websites, and written communication to support claim processing.
• Tracks missing insurance payment information, keeps management informed of trends, and stays current on changes in billing requirements related to claim processing and coding.
• Escalates issues that may prevent completion of responsibilities.