Claims Resolution Specialist

Role Overview

• Investigate and resolve claim rejections, denials, and payer edits identified before or after claim submission
• Review claim history, payer correspondence, medical records, authorizations, and supporting documentation to determine the cause of claim issues
• Correct billing, coding, demographic, authorization, and insurance-related claim errors as appropriate
• Process claim corrections, adjustments, resubmissions, and reconsideration requests in accordance with payer guidelines
• Perform payer research and communicate directly with insurance carriers to resolve claim processing issues
• Monitor assigned work queues and ensure timely resolution of outstanding claims
• Escalate complex reimbursement, coding, or compliance issues to senior team members
• Partner with A/R and Denials Management teams to resolve denied and underpaid claims
• Assist in preparing appeal documentation and supporting materials for denied claims
• Identify recurring denial patterns and communicate findings to the Senior Claims Resolution Coordinator
• Maintain accurate documentation of denial resolution activities and payer communications
• Support efforts to reduce preventable denials and improve reimbursement outcomes
• Work closely with the pre-billing team to identify and correct claim issues prior to submission
• Review claims for completeness and compliance with payer billing requirements
• Verify insurance information, authorizations, referrals, diagnosis coding, procedure coding, and modifier usage
• Collaborate with coding and clinical teams to obtain information needed for claim resolution
• Assist with reducing claim holds and billing delays
• Participate in routine claim quality reviews and internal audit activities
• Ensure claim corrections comply with payer regulations, organizational policies, and billing guidelines
• Support Revenue Integrity initiatives through accurate claim review and documentation
• Maintain knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial payer requirements
• Adhere to HIPAA, CMS, and organizational compliance standards
• Maintain detailed documentation of claim investigations, resolutions, payer communications, and follow-up activities
• Track assigned workloads and resolution outcomes
• Assist with compiling information for denial trend reporting and operational reviews
• Provide feedback regarding workflow issues contributing to claim errors or payment delays
• Assumes other responsibilities as appropriate to the position and organizational needs

Requirements

• High School Diploma or equivalent required
• Associate degree in Healthcare Administration, Medical Billing and Coding, or related field preferred
• Minimum 2-4 years of experience in medical billing, claims resolution, denial management, accounts receivable, or healthcare revenue cycle operations
• Working knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial insurance billing requirements
• Knowledge of CPT, ICD-10-CM, HCPCS, modifiers, and medical terminology
• Experience researching and resolving denied or rejected claims
• Strong analytical and critical thinking skills
• Ability to manage multiple priorities and meet productivity expectations.

Benefits

• Amazing work/life balance
• Generous Medical, Dental, Vision, and Prescription benefits (PPO & HMO)
• 401(K) Plan with Employer Matching
• License & Tuition Reimbursements
• Paid Time Off
• Holiday Pay & Floating Holiday
• Employee Perks and Discount Programs
• Supportive environment to help you grow and succeed