Account Resolution Rep II PB

cwi; West Allis (WI); On-site; USD 52,000 - 67,000; Full time

Job summary

Children's Wisconsin is seeking a dedicated Professional Billing Specialist to resolve complex service insurance denials and maximize reimbursement from third-party payers. You will follow up on claims, review payer guidelines, and collaborate with the billing and coding teams to ensure accurate payments.

A minimum of 3 years in healthcare revenue cycle, knowledge of CPT/ICD-10, and strong communication are required.

Qualifications

• High School diploma or GED required; hospital revenue cycle experience preferred.
• 3 years of claims follow-up and reimbursement experience in healthcare.
• Strong knowledge of CPT-4/ICD-10 and payer guidelines.

Responsibilities

• Resolves complex service insurance denials and seeks maximum reimbursement.
• Performs follow-up with guarantors and insurance companies and resubmits claims.
• Reviews payer guidelines and applies modifiers for accurate payments.
• Identifies coding issues and collaborates with leadership and coding teams.
• Analyzes denials, tracks trends, and communicates findings to management.
• Submits appeals and maintains documentation for payer follow-up.
• Maintains understanding of A/R, policies, and productivity standards.
• Utilizes payer websites to verify eligibility and claim status.

Skills

Medical terminology

ICD-10/CPT knowledge

Analytical skills

Communication skills

Teamwork

Microsoft Office

Education

High School diploma or GED

Tools

Epic Resolute

MS Office

Job description

At Children's Wisconsin, we believe kids deserve the best. Children's Wisconsin is a nationally recognized health system dedicated solely to the health and well‑being of children. We provide primary care, specialty care, urgent care, emergency care, community health services, foster and adoption services, child and family counseling, child advocacy services and family resource centers. Our reputation draws patients and families from around the country.

Job Summary:

Researches and resolves Professional Billing complex service insurance denials and ensures that claims are paid at maximum reimbursement from third party payers, state programs and contracted organizations for Children's Wisconsin.

Essential Functions:

• Performs various follow‑up actions including contacting guarantors, insurance companies, updating registration, correcting and resubmitting claims, filing appeals in order to achieve claim resolution.
• Maintains current knowledge of managed care payer contracts and third party payer billing guidelines and policies for assigned payers (Commercial/Government).
• Follows‑up on assigned work queues to ensure proper reimbursement based on assigned payer timely filing guidelines.
• Identifies coding issues relating to CPT‑4 and ICD‑10 and use of appropriate modifiers to obtain maximum reimbursement. Collaborates with leadership and coding team on resolution.
• Analyzes and investigates complex insurance denials, identify and/or track trends associated to assigned payers. Keeping leads and management appraised of identified issues having an impact on reimbursement.
• Submits written and online correspondences and appeals to payers as needed to obtain appropriate payment.
• Reviews and recommends adjustments of claims to management. Applies account adjustments when appropriate.
• Utilizes payer websites to verify patient insurance information, claim status/payments/denials and/or to appeal online as necessary to obtain proper payment on claims.
• Maintains a thorough understanding of A/R functions, department policies and procedures. 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) required

Experience:

• 3 years experience in claims follow up in health care revenue cycle operations including reimbursement procedures and comprehension of insurance EOB's required
• Prior experience in a hospital system working with professional billing claims and functions preferred
• Inpatient and surgical medical billing experience preferred
• Mental Behavioral Health billing experience preferred
• Experience in Epic Resolute preferred

Knowledge, Skills and Abilities:

• Working knowledge of medical terminology, ICD-10, CPT and HCPCS level II codes.
• Strong understanding of payer guidelines, policies and procedures.
• Excellent verbal and written communication skills.
• Ability to work independently with minimal supervision.
• Strong analytical skills and ability to perform noncomplex arithmetic calculations when determining contractual allowances.
• Must have working knowledge of account reconciliation and third party reimbursements from Commercial, Medicaid and Medicare Carriers.
• Interpersonal skills necessary to efficiently respond to questions from patients, parents, clinic staff and insurance companies to effectively resolve billing issues.
• 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.
• Proficient in Microsoft Office applications and technology skills required to perform duties.

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 otherwisre.

Please follow this link for a closer look at what it's like to work at Children's Wisconsin: https://www.instagram.com/lifeatcw/

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.