Resolve complex post-payment and denied DME claims
Independently manage a portfolio of high-priority and complex claims requiring advanced solutions and strategies
Analyze denials, overpayments and underpayments to determine root cause
Submit technical, clinical and medical necessity appeals at all levels
Research payer contract language, LCD/NCD guidelines and policy updates
Identify payer trends and escalate issues with supporting data to payer contacts and leadership
Resolve escalated issues involving prepay audits, refund requests, rebills, recoupments and coordination of benefits discrepancies
Manage HCFA returns and claim corrections
Communicate effectively with leadership and cross-functional teams
Ensure account documentation is accurate, detailed, and audit ready across all internal system
Consistently meet or exceed departmental metrics related to productivity, quality, aging resolution, and cash recovery.

High School Diploma or Equivalent
Minimum 2+ years of medical collection or revenue cycle experience with emphasis on post-billing DME or orthopedic claims
Advanced knowledge of payer guidelines, revenue cycle management, and appeals processes (Medicare, Medicare advantage, Medicaid, and commercial insurance payers)
Proficiency 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
Demonstrated experience with complex denials, payer escalations, and appeals at all levels
Strong attention to detail with the ability to identify trends and implement corrective strategies
Excellent communication skills and negotiation skills with payers and internal stakeholders.
Ability to work independently, Detail-oriented with a focus on accuracy, time-management and compliance.

Health Claims Specialist II

Key skills