Clm Resltion Rep III, Hosp

Rochester, NY



Rochester Tech Park (RTP), Gates, NY - Remote options available after in-person training. Occasional onsite meetings / work at RTP are required. Remote location must be within 2 hours of RTP and within New York State.

Position Summary :

With latitude for initiative and independent judgment within department guidelines, the position is responsible for managing professional hospital accounts. Activities performed will focus on resolving balances of aged insurance accounts which have not been collected through routine billing and collection activities. Claim Resolution Rep III will make independent decisions as to the processes necessary to collect denied insurance claims, no response accounts, and will investigate resolving billing issues. Maintain a detailed knowledge of billing requirements and regulations to ensure that the process conforms to federal and state regulations bringing concerns to the attention of billing Manager and Supervisor. The Claim Resolution Rep III will represent the department and Strong Memorial Hospital (SMH) in a professional manner, protecting confidentiality of patient information at all times.

Supervision and Direction Exercised :

The Claim Resolution Rep III is responsible for self-monitoring performance on assigned tasks, following standard procedures as directed by the Supervisor or 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, Microsoft Word, Excel, Access, Email, third party claims systems (ePaces, Connex), Epic Billing System, and various payer web sites.

Typical Duties :

40% Completes follow up activities on denied, unpaid, or under-paid accounts by use of EPIC Insurance Coverage or the Payer Website link, online systems with insurance companies, and other third-party payers to obtain payments, as well as contact payer representatives to research/resubmit rejected claims to obtain and verify insurance coverage.

  • Follow up on unpaid accounts working claim activity in EPIC

  • Works in assigned EPIC follow up workqueue(s).

  • Review reason for claim denial – reason code or denial codes in EPIC.

  • View Payer Website link (EPIC Insurance Coverage tab), review payer website, or contact payer representative as to why claims are not paid.

  • Determines steps necessary to secure payment and completes EPIC Follow up Activity by resubmitting claim or deferring task.

  • Documents all account follow up activity.

  • Research and calculate under or overpaid claims; determine final resolution

  • Review and determine correct follow up.

  • Contact payer on incorrectly paid claim completing resolution and adjudication.

  • Adjust account or process insurance refund credits.

  • Review and advise supervisor or manager of trends on incorrectly paid claims from specific payers.

  • Work with supervisor/manager on communication to payer representatives regarding payment trends and issues.

30% Maintains a thorough knowledge of Professional Billing to include understanding of policies and procedures related to insurance collection and follow up.

  • Bills primary and secondary claims to insurance.

15% Identify and clarify billing issues, payment variances and/or trends that require management intervention; share with Supervisor and/or Manager. Assist Supervisor with credit balance account review/resolution and all audits

  • Coordinate responses and resolution to Medicaid and Medicare credit balances.

  • Request insurance adjustments or retractions.

  • Review and work all insurance credits in EPIC.

  • Enter EPIC note documenting action taken.

10% Research and respond to third party correspondence, receive phone calls, explain policies and procedures involving routine and non-routine situations. Assist with patient related questions. Communicates with other URMFG, HIM, Revenue Integrity, Registration and Insurance Management, PFS, EPIC Single Billing Office, and SMH departments.

  • Coordinate with other department within SMH to get claim issues resolved.

  • Assists will all audits as needed.

5% Other miscellaneous duties


  • Participate in department staff meetings, education classes and training

  • Stay current on HIPAA guidelines through education and reading monthly emails

  • Participate in URMC training such as Strong Commitment ICare and Annual Mandatory In-Service

  • Join PFS committees such as Planning PFS events or addressing employee issues

  • Maintains proficiency in EPIC for Insurance Follow up and clear understanding regarding how EPIC department functions interrelate for the overall success of the Hospital Provider Based 1500 billing group


Associate's degree in Business Administration and 2 years of hospital/professional Patient Accounting, Consumer Collections experience, or Certification obtained from a nationally accredited billing program (i.e., Certified Medical Billing Specialist CMBS, Certified Medical Records Technician CMRT, Certified Medical Reimbursement Specialist CMRS); or an equivalent combination of education and experience. Ability to type 25 wpm.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion 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 status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $19.62 - $26.49 Hourly

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.

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Location: Strong Memorial Hospital
Full/Part Time: Full-Time