Clm Resltion Rep IV, Hosp - Remote/Hybrid Opportunity

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 considerable latitude for independent judgment, the Claim Resolution Rep IV is responsible for the follow up and collection of accounts that are complex based on high dollar amounts, multiple payers, unique billing or payment arrangements, specialized services (e.g. transplants, studies) as well as governmental and/or community contracts. Revenue collection activities focus on all payers which are billed under unique contractual obligations on both primary and secondary levels. Trains new and existing PFS staff on new procedures and acts as point person for complex accounts. Serves as main point of contact in claim resolution process for Strong Memorial Hospital (SMH) clinical staff and outside agencies regarding contractual obligations. Assures on-going positive relations and support of highly-visible unique contracts and arrangements. The Claim Resolution Rep IV will represent the department and SMH in a professional manner, protecting confidentiality of patient information at all times.

Supervision and Direction Exercised:

The Claim Resolution Rep IV is responsible for self-monitoring performance on assigned tasks and trains and coordinates activities of peers and lesser-grade staff, as directed by the Supervisor. Independent judgment is necessary in escalating collection activities and determining violation of contracts.

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:

30% Complex, High Dollar & Specialized Services Account Resolution

  • Through detailed knowledge of all third-party payer billing requirements and governmental contracts, independently determines the most effective method to follow up on disputed, unpaid, underpaid or overpaid insurance or contracted service accounts in order to bring about prompt account resolution and revenue collection from complex claims, high dollar claims and specialized services (global transplant, studies and grants, etc.)

  • Identifies and resolves problems related to both primary and secondary accounts which are disputed, unpaid, underpaid or overpaid. Determines cause of problem and initiates corrective action through reviews of electronic medical records.

  • Using tact and finesse contacts and confers with contractual agencies (e.g. Veterans Administration), Department of Health, third party and governmental payers, clinical department providers and staff, Workers’ Compensation Board and Health Information Management Coding staff, etc. to resolve accounts.

  • Analyzes accounts and determines if correct proration of revenue has been collected using detailed understanding and application of all payer contracts (primary and secondary). Contacts applicable agency, payer or department for resolution.

  • Independently decides when re-submission efforts are complete, including writing an appeal using applicable content and supporting documentation in order to appropriately influence the highest level of revenue.

20% PFS Support

  • Acts as a point person for questions from assigned PFS collection and billing staff on payer policies, procedures and methods of revenue collection.

  • Trains new PFS staff on the use of the billing application, payer systems and clearinghouse system. Demonstrates how to apply the knowledge of payer contracts and resources in order to resolve disputed, unpaid, underpaid or overpaid accounts.

  • Provides feedback to Operations Supervisor on results of training of new and existing staff.

  • Provides input for performance assessments (probationary and annual) based on observation, questions, and quality review of work performed.

  • In the absence of the Operations Supervisor, acts as the authority, including responding

to payers, patients, and issues referred to the area from hospital departments or Patient Service Representatives.

15% Designated Support

  • Researches and responds to SMH clinical department inquiries on complex, high dollar and specialized accounts and status of collection activities affecting departmental revenue.

  • Using sensitivity and judgment decides if/when patients are contacted. Resolves complex, high dollar and specialized claim resolution issues due to coordination of benefits (multiple payers), eligibility issues, and authorizations.

15% Audits, Post-Claim Authorizations and Reimbursement Allocation

  • Resolve accounts identified in third party audits involving retroactive approvals, resulting in adjustments, refunds and subsequent secondary billing.

  • Research, verify or obtain authorizations post-claim submittal requiring detailed knowledge of payer rules, complex account procedures and additional documentation to support payment of services.

  • Determines allocation of reimbursement applicable to multiple providers for global transplant payments and initiates transfer of dollars to each provider.

10% Payer Relations

  • Identifies need for in-person meetings and phone conferences with third-party insurance representatives due to claim and systems issues requiring prompt attention for complex high dollar accounts.

  • Prepares information for and attend meetings with third-party insurance representatives on claims and systems issues for scheduled in-person meetings and phone conferences regarding complex high dollar claims.

5% Escalation Process

  • Identify and clarify issues that require management intervention to avoid loss of revenue.

  • Recommends the filing of a formal complaint with the State’s regulation commission or agency.

  • Determines when to change the account to a self-pay financial class after a review of previous efforts has not resulted in revenue collection and further attempts would not be successful without patient intervention.

5% Additional duties as assigned:

  • Research and initiate suggestions to Supervisor to streamline processes and training materials.

  • Perform coverage for other positions and other duties of similar scope and complexity in regular combination with this position.

  • Copying, faxing, mailing claims, printing and preparing accounts for being written off.

  • Maintains records for effective reporting.


  • Participate in department meetings, educational classes and training

  • Attend monthly department staff meeting and team meetings

  • Stay current on HIPAA guidelines through education and reading emails

  • Participate in educational training such as Strong Commitment ICare and Annual Inservice

  • Join PFS committees such as planning PFS events or addressing employee issues.


Requires: Associate’s degree in business field and 4-5 years of experience in hospital billing, accounting, and/or coding; 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 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: $20.99 - $28.34 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