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Lead Insurance Claims Resolution Specialist
2 months ago
At University of Toledo Physicians, our commitment is to enhance the human experience through outstanding patient care and innovative medical research. With a team of over 200 physicians, we excel in clinical services, research, and the education of future healthcare professionals, offering a comprehensive range of medical specialties from intricate diagnoses to primary care for families.
We provide competitive compensation and benefits, including a 403B plan, pension options, health coverage, and tuition waivers at the University of Toledo.
The Lead Insurance Claims Resolution Specialist is responsible for executing job functions in alignment with established protocols, policies, and detailed guidelines, driving resolution and fostering optimal performance while achieving exceptional revenue cycle results. This role involves daily interactions with team members, insurance representatives, and various departments to efficiently resolve outstanding account balances, enhance patient experiences, and uphold a code of conduct that ensures integrity and compliance. This position acts as a subject matter expert in the field.
KEY RESPONSIBILITIES:
- Accurately documents all communications and actions taken to achieve claim or account resolution within the practice management system.
- Demonstrates effective communication skills and a positive demeanor with both internal (team members, other departments, providers, and leadership) and external stakeholders (patients, insurance companies, vendors, and employers). Directs unresolved customer complaints to management for prompt attention.
- Adheres to workflow processes to guarantee accurate registration, coding, payment/adjustment posting, and insurance claim processing.
- Conducts verbal and written inquiries to ascertain reasons for unpaid or denied claims to facilitate resolution.
- Effectively manages claims within assigned worklists to meet or exceed productivity benchmarks.
- Contributes as a team member by undertaking additional tasks not directly related to the job description when workload demands and as directed by management.
- Prioritizes and organizes work to meet deadlines based on importance.
- Ensures claims are submitted to the appropriate responsible parties within designated filing limits and prioritizes claim resolution as a departmental focus.
- Identifies and investigates problematic trends related to non-payment to implement preventive strategies that enhance cash collection efficiency.
- Travels to various practice locations to provide on-site support and engages in regular meetings with practice leadership to promote positive revenue cycle performance.
- Maintains confidentiality of all patient records and accounts.
- Actively participates in staff meetings and process improvement initiatives.
- Keeps work areas organized and ensures all source documents are electronically stored on the shared network.
- Understands and adheres to HIPAA policies and procedures, ensuring the confidentiality of protected health information (PHI) in compliance with HIPAA regulations.
- Performs additional duties as assigned.
QUALIFICATIONS:
- Education: High School diploma or equivalent.
- Experience: Minimum of 2 years in resolving insurance denials and/or revenue cycle management.
- Skills:
- Basic understanding of insurance requirements, regulations, contract benefits, credit and collection procedures, and financial assistance programs, along with familiarity with medical terminology.
- Advanced reading, writing, and oral communication skills, with the ability to perform mathematical calculations.
- Interpersonal skills necessary for effective communication with patients and third-party payers. Ability to work amidst interruptions from co-workers or other internal customers needing assistance with patient accounts.
- Analytical and critical thinking skills to diagnose account issues, along with active listening skills to ensure service excellence. Proven project and time management abilities, with a capacity to work effectively both over the phone and in a team setting.
- Demonstrated proficiency in data entry and computer usage.
PREFERRED QUALIFICATIONS:
- Skills:
- Knowledge of CPT and ICD terminology.
- Familiarity with billing software.
- Experience with EPIC systems.
The responsibilities outlined above are intended to convey the general nature and level of work performed by individuals in this classification. They are not intended to be an exhaustive list of all duties performed by employees in this role, nor do they limit the supervisor's right to assign, direct, and control the work of employees under their supervision.
We are an Equal Opportunity Employer and maintain a Drug-Free Workplace.
