Claims Resolution Specialist

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

📋 Description

• The Claims Resolution Specialist is integral to the healthcare revenue cycle, ensuring the precise and prompt submission and resolution of both insurance and patient claims.

• This role encompasses claim billing, follow-up, and resolution for government, commercial, and patient payers.

• The specialist examines denied or unpaid claims, conducts root cause analysis, documents findings, executes necessary write-offs or adjustments, and guarantees adherence to payer guidelines and internal policies.

• Submit and monitor insurance and patient claims for government (e.g., Medicare/Medicaid) and commercial payers.

• Conduct timely and comprehensive follow-up on unpaid or denied claims to secure proper reimbursement.

• Perform root cause analysis on recurring denial or payment issues; escalate patterns to management as required.

• Investigate payer policies and claim-specific requirements to ensure accurate resolution of claims.

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

• Maintain clear, precise, and thorough documentation of all activities and communications related to claims.

• Collaborate with clinical, billing, and coding teams to resolve claim issues and ensure accurate submissions.

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

• Prepare reports and summaries concerning problematic accounts, denial trends, and process inefficiencies for leadership review.

• Assist in implementing process enhancements to minimize denials and improve revenue cycle performance.

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

• Perform other duties as assigned.

⛳️ Requirements

• A 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.

• Proficient understanding of 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 to a fast-paced environment.

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

• Strong data entry and documentation abilities.

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

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

🏝️ Benefits

• Remote work

• Flexible hours