Claims Resolution Specialist

Job SummaryConduct follow-up with payors, vendors, and clearinghouse on open insurance claims and balances in compliance with departmental policies and procedures. Resubmit primary and secondary claims. Identify potential claim issues and escalate to management. Review, identify, and resolve root causes of payor denials. Ensure that claims are processed accurately to prevent financial losses for both patients and providers. Claims specialists strive for timely resolution to avoid delays in reimbursement. Complete any other projects that are assigned that have a direct impact on billing department revenue cycle.Essential Responsibilities and MetricsResearching claim denials.Submitting appeals.Following up on outstanding claims.Handling claims correspondence.Reviewing and processing insurance claims in a timely and accurate manner.Investigating and resolving complex claim issues.Maintaining detailed records of all claims activity.Communicating regularly with policyholders, claimants, and insurance carriers.Qualifications:Medical Terminology:

A solid understanding of medical vocabulary is crucial for interpreting diagnoses, procedures, and coding accurately.Insurance Claims:

Proficiency in handling Commercial insurance claims, including reviewing, processing, and understanding policy coverage.Data Entry:

Accurate and efficient data entry skills are essential for managing claims information.Patient Accounts:

Familiarity with managing patient accounts, coordinating payment arrangements, and updating insurance details.Medicaid Knowledge:

Understanding Medicaid processes and requirements.CPT Coding:

Knowledge of Current Procedural Terminology (CPT) codes used in medical billing.Phone Communication:

Ability to make outbound calls to provider reps to effectively dispute underpaid claims.

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