Claims Resolution Specialist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Submit and monitor insurance and patient claims for both government and commercial payers.

• Conduct timely follow-ups on unpaid or denied claims to ensure appropriate reimbursement.

• Perform root cause analysis on frequent denials or payment issues and escalate trends to management.

• Investigate payer policies and claim-specific requirements.

• Process write-offs and adjustments in accordance with established protocols and payer contracts.

• Maintain clear and accurate documentation of claim-related activities and communications.

• Collaborate with clinical, billing, and coding teams to resolve claim-related issues.

• Monitor aging reports and prioritize follow-up based on payer deadlines and financial implications.

• Prepare reports and summaries regarding problematic accounts, denial trends, and process inefficiencies.

• Assist in implementing process improvements aimed at reducing denials and enhancing revenue cycle performance.

• Ensure compliance with HIPAA regulations, payer guidelines, and internal billing policies.

• Perform additional duties as assigned.

⛳️ Requirements

• High school diploma or equivalent is required; an associate's or bachelor's degree in healthcare administration, business, or a related field is preferred.

• A minimum of 2 years of experience in medical billing, claims follow-up, or revenue cycle management is required, preferably in Orthopedics.

• Familiarity with government and commercial payer guidelines, medical terminology, CPT/ICD-10 coding, and insurance billing practices.

• Experience with Electronic Health Record (EHR) and Practice Management systems (e.g., ModMed, Epic, Athena, etc.).

• Ability to work independently, meet deadlines, and adapt in a dynamic environment.

• Experience in communicating with patients regarding billing inquiries and payment options is a plus.

• Strong data entry and documentation capabilities.

• Proficient in Microsoft Office Suite, especially Excel and Outlook.

• Understanding of claim adjudication, payment posting, and denial management processes.

• Ability to perform office tasks, including remaining seated for computer-based work, filing, and lifting/carrying office supplies.

• Occasionally required to lift and/or move up to 20–25 pounds.

• Travel may be necessary to existing or new OCP locations.

🏝️ Benefits

• Comprehensive healthcare coverage.

• Retirement savings plan with company match.

• Opportunities for professional development and growth.

• Flexible work arrangements.

• Paid time off and holidays.