Credit Balance Resolution Specialist

Position Summary

The Credit Balance Resolution Specialist is responsible for resolving credit balances, undistributed payments, and requests for refunds due to insurance companies, patients/guarantors, or other payers through phone, fax, and written correspondence. This position works with internal and external customers (e.g., third‑party payers, patients/guarantors, estate representatives, attorneys, employers, and ECU Health employees) to facilitate the prompt resolution of credit balances or refunds.

This role involves researching insurance benefits, understanding coordination of benefits between payers, distributing/reapplying or transferring payments to the appropriate date of service/provider or account, updating account adjustments, generating refund requests, addressing over payment notifications, and denying refund requests according to policy/contract guidelines. Accurate and timely resolution of overpays, undistributed payments, and requests for refunds is based on knowledge of contractual obligations and regulatory requirements.

• Conduct timely and accurate review of credit balances, undistributed payments and requests for refunds to determine the appropriate course of action needed.
• Initiate refunds to patients/guarantors, insurance companies, and other third parties by following established refund procedures, contractual obligations, payer and regulatory requirements.
• Conduct timely and accurate review of refund requests from payers with contracted recoupment language to reduce future recoupment reconciliations.
• Review, validate and correct adjustments on accounts based on insurance reimbursement, benefit coverage guidelines, contracted payers and services provided.
• Redistribute and/or transfer payments between PB/HB accounts.
• Validate and update patient demographic and insurance information to ensure accuracy of future claims.
• Reconcile misdirected and clearing accounts by researching and posting payments to the correct accounts.
• Ensure correct reimbursement rates are reflected in refund requests.
• Maintain appropriate and accurate system documentation with notes and standard note codes.
• Adhere to Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.
• Review and resolve accounts assigned via work lists daily as directed by management.
• Support the Team Lead, and Manager as needed.

• High school diploma, equivalent or higher.
• Minimum of five years of experience in insurance, finance, medical office, or customer service‑related field.
• Knowledge of managed care contract billing guidelines is required.
• Revenue Cycle (healthcare business, financial, or insurance) experience.
• Epic experience.
• Knowledge of medical and insurance terminology, CPT, ICD & HCPCS coding structures, and billing forms (UB, 1500).

• Successful achievement of the following:
  • Must have excellent time management skills and be able to handle multiple, simultaneous tasks effectively and efficiently while maintaining a professional, courteous manner.
  • Must be able to work well with others.
  • Strong verbal and written communication skills required.
  • Must be detail oriented and organized.
  • High integrity, including maintenance of confidential information.
  • Must be able to exercise good judgment and positively influence and lead others, including handling confrontations with poise and efficiency.
  • Illustrates autonomous, best revenue cycle practices.
  • Illustrates proficiency in the use of all internal automation and software applications.

• Strong problem‑solving skills.
• Strong quantitative, analytical and organizational skills.
• Advanced understanding of an Explanation of Benefits (EOB).
• Knowledge of CPT, ICD-10, and HCPCS coding standards.
• Understand CMS Memos and Transmittals.
• Utilize and understand computer technology.
• Communicate orally and in written form.
• Ability to manage multiple tasks with ease and efficiency.
• Self‑starter with a willingness to try new ideas.
• Ability to work independently and be result oriented.
• Understand insurance terms and payment methodologies.

• Onsite position (based out of…