Health Claims Collections Specialist II

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

📋 Description

• Take charge of a portfolio consisting of high-priority and intricate claims that necessitate advanced solutions and strategies.

• Examine denials, overpayments, and underpayments to identify the root causes; implement action plans that include appeals, escalations, and payer outreach.

• Prepare technical, clinical, and medical necessity appeals at all levels, including external reviews, while providing supporting documentation.

• Investigate payer contract language, LCD/NCD guidelines, and policy updates; apply the findings to claims resolution and inform peers and leadership of any relevant changes.

• Detect payer trends such as systemic rejections, denials, overpayments, or underpayments, and escalate issues with supporting data to payer contacts and leadership.

• Resolve escalated matters involving prepay audits, refund requests, rebills, recoupments, and discrepancies in coordination of benefits.

• Administer HCFA returns and claim corrections, ensuring clean resubmissions according to billing guidelines.

• Collaborate with leadership and cross-functional teams to address complex claim barriers.

• Ensure that account documentation is precise, thorough, and ready for audits across internal systems.

• Achieve or surpass departmental metrics related to productivity, quality, aging resolution, and cash recovery.

• Act as a subject matter expert for junior collectors and assist leadership in enhancing payer compliance and revenue recovery.

⛳️ Requirements

• High School Diploma or Equivalent Experience

• A minimum of 2+ years in medical collection or revenue cycle experience, particularly focused on post-billing DME or orthopedic claims.

• Advanced understanding of payer guidelines, revenue cycle management, and appeals processes (including Medicare, Medicare Advantage, Medicaid, and commercial insurance payers).

• Proficient in reading and interpreting EOBs, payer policies, LCDs, and prior authorization requirements.

• Strong working knowledge of ICD-10, HCPCs, and billing procedures for CMS-1500 claim forms.

• Proficient in Microsoft Office and medical billing platforms.

• Proven experience dealing with complex denials, payer escalations, and appeals at all levels.

• Exceptional attention to detail, with the ability to identify trends and implement corrective measures.

• Outstanding communication and negotiation skills with payers and internal stakeholders.

• Capacity to work independently, with a detail-oriented approach focused on accuracy, time management, and compliance.

• Familiarity with Oracle or similar revenue cycle platforms.

• Associate’s degree is preferred.

🏝️ Benefits

• Bonus

• Benefits

• Equal employment opportunities

• Reasonable accommodations for qualified individuals with disabilities