Take ownership of complex, aged or escalated accounts requiring detailed investigation, negotiation and strategic follow-through across all payer types.
Lead resolution of complex accounts involving prepayment audits, clinical appeals, payer escalations and refund/recoupment cases.
Analyze payer trends and systemic denial issues; initiate internal reviews and collaborate with management to develop and implement corrective strategies.
Serve as a subject matter expert (SME) on payer policy changes, contract interpretation, billing guidelines and compliance risks.
Assist with the development and refinement of work instructions, standard appeal templates and escalation pathways.
Act as a lead and mentor to level I and II Accounts Receivable Specialists, assist with training, guidance on payer processes, documentation standards and communication techniques.
Coordinate with internal stakeholders as needed to ensure proper handling of disputed claims and revenue impacting issues.
Participate in in payer calls or external meetings to represent the organization in resolving complex reimbursement barriers.
Ensure accurate and thorough documentation in account records.
Collaborate with Specialist level IIII and leadership to identify process gaps, recommend system enhancements and assist with special projects or reporting as needed.
Consistently achieve departmental metrics and actively contribute to team performance targets and cash goals.

4+ years of progressively responsible experience in Orthofix medical collections, revenue cycle, or DME claims management.
Advanced understanding of DME billing, payer policies (Medicare, Medicare Advantage, Medicaid, Commercial payers, Litigation, Work Comp, Auto) and appeals lifecycle.
Demonstrated experience in managing high-complexity claims, payer escalations, and cross-departmental collaboration.
Expertise in interpreting contracts, payer fee schedules, EOBs, LCD/NCD guidelines, Clinical and reimbursement strategies.
Strategic thinker with a strong understanding of reimbursement policy, payer operations, and healthcare regulations.
Exceptional analytical, investigative, and documentation skills with the ability to explain and defend decisions.
Excellent mentoring, training and leadership presence in team environments.
Comfortable leading and participating in discussions with payers and presenting data to leadership.
Proficient in revenue cycle systems, and Microsoft excel.
Self-directed, accountable, and able to manage shifting priorities in a high-volume environment.

Health Claims Specialist – Senior

Key skills