University of Rochester

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

905 Elmgrove Rd, Bldg 5 Rm 2D008, Rochester, New York, United States of America, 14624

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500011 Patient Financial Services

Work Shift:

UR - Day (United States of America)

Range:

UR URCB 204 H

Compensation Range:

$18.71 - $25.27

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

GENERAL PURPOSE

The Claim Resolution Rep II is responsible for the accurate and timely preparation and submission of third-party billing/claims to governmental or third-party payers. Re-submits claims that fail third party edits and submits second level claims. Provides guidance and support to Billing Assistant and answers correspondence. The Claim Resolution Rep II will represent the department and Strong Memorial Hospital (SMH) in a professional manner, protecting confidentiality of patient information at all times.

ESSENTIAL FUNCTIONS

Supervision and Direction Exercised:

Responsible for monitoring own performance on assigned tasks against procedure standards. May train and coordinate activities of peers as directed by Supervisor, Revenue Cycle Management and Manager.

Machines and Equipment Used:

Standard office equipment, including but not limited to: telephone, photocopy machine, adding machine, personal computer (for claims inquiry and entry software) fax/scanner, Flowcast billing application, Microsoft Word, Excel, Access, Email, Emdeon (Fidelis Medicaid Managed Care and Medicare Part B) clearinghouse software, third party claims systems (ePaces, Omnipro) and various payer web sites.

Typical Duties

35% Researches and corrects primary payer claims that have failed to process.

• Using knowledge of payer billing software makes corrections directly in payer system.
• Identifies non-routine problems for claims requiring correction and decides action for correction by reviewing bill types and interpreting visit notes.
• Resolves non-routine upfront edits on Emdeon which include but are not limited to modifier requirements or provider enrollment issues. Identifies claims that require further research and determines source of correction and initiates request through PAO supervisors or appropriate clinical department. Tracks pending claims and makes appropriate correction once answer has been received.
• Notifies the team Supervisor, Revenue Cycle Management when the amount of edits holding exceeds normal target ranges. Prepares written summary of the issues regarding the edits.
• Documents all actions thoroughly in visit notes.

30%Submits secondary payer claims.

• Prepares paper claims for secondary submission using knowledge of secondary payer unique requirements and processes. Provides primary payment information and determines adjustment information and applicable details required for each claim.
• Determines when a “no-pay” claim request must be submitted to a primary payer in order to obtain a denial sufficient to be sent to the secondary payer. Reviews claim data and modifiers as well as secondary payer and patient requests prior for appropriateness of secondary payer submission.
• Compares primary payment to the anticipated secondary payment to determine whether or not to follow secondary payer submission process. Using knowledge of payer rules submits secondary bills after confirming that an additional payment is due.
• Resolves non-routine upfront edits on Emdeon which include but are not limited to modifier requirements or provider enrollment issues. Identifies claims that require further research and determines source of correction and initiates request through PAO supervisors or appropriate clinical department. Tracks pending claims and makes appropriate correction once answer has been received.
• Documents all actions thoroughly in visit notes.

30% Corrects claim errors returned post-submission.

• Reviews claims requiring non-routine correction in payer system to determine method of correction.
• Adjusts claims through manual process to ensure highest level of reimbursement. Determines cause of error to identify appropriate source that can supply applicable missing information (e.g. modifiers, medically unlikely edits). Tracks pending claims and makes appropriate correction once answer has been received.
• Identifies the correction method needed when additional modification of a claim triggers an additional edit. Finalizes claim submission following resolution.

5% Other duties as assigned:

• Provides guidance and support to Billing Assistants
• Manually keys/ enters late charges on 141 bills in Omnipro
• Answers correspondence

Expectations:

• Participate in department/team staff meetings, educational classes and training
• Attend monthly department and team staff meetings
• Stay up to date on HIPAA guidelines through education and reading monthly emails
• Participate in educational training such as Strong Commitment, ICare and Annual In- Service
• Join PAO committees such as planning PAO events or addressing employee issues
• Attend weekly meetings

QUALIFICATIONS

• Minimum Education & Experience: High School diploma and 2 years of related work experience or equivalent combination of education and experience.
• Preferred: Associate's degree in Accounting and 1 year of related accounting or collection experience; or an equivalent combination of education and experience.

NOTE: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

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