Claims Resolution Specialist

Claims Resolution Specialist

The Claims Resolution Specialist plays a critical role in the healthcare revenue cycle by ensuring the accurate and timely submission and resolution of insurance and patient claims. This position is responsible for claim billing, follow-up, and resolution for government, commercial, and patient payers. The specialist investigates denied or unpaid claims, performs root cause analysis, documents findings, executes appropriate write-offs or corrections, and ensures compliance with payer guidelines and internal policies. The ideal candidate demonstrates strong analytical skills and persistence in problem-solving to support the organization's financial health.

Essential Functions Include, But Are Not Limited To:

• Submit and track insurance and patient claims for government (e.g., Medicare/Medicaid) and commercial payers.
• Perform timely and thorough follow-up on unpaid or denied claims to ensure proper reimbursement.
• Conduct root cause analysis on recurring denials or payment issues; escalate trends to management as needed.
• Research payer policies and claim-specific requirements to ensure accurate claim resolution.
• Process write-offs and adjustments according to established protocols and payer contracts.
• Maintain clear, accurate, and thorough documentation of all claim-related activities and communications.
• Collaborate with clinical, billing, and coding staff to resolve claim issues and ensure accurate claim submission.
• Monitor aging reports and prioritize follow-up efforts based on payer deadlines and financial impact.
• Prepare reports and summaries of problem accounts, denial patterns, and process inefficiencies for leadership review.
• Assist in implementing process improvements to reduce denials and enhance revenue cycle performance.
• Ensure compliance with HIPAA, payer guidelines, and internal billing policies.
• Performs other duties as assigned.

Requirements

Minimum Requirements / Qualifications

• High school diploma or equivalent required; associate's or bachelor's degree in healthcare administration, business, or related field preferred.
• 2+ years of experience in medical billing, claims follow-up, or revenue cycle management required, preferably in Orthopedics.
• Working knowledge of government and commercial payer guidelines, medical terminology, CPT/ICD-10 coding, and insurance billing practices.
• Experience with Electronic Health Record (EHR) and Practice Management systems (e.g., ModMed, Epic, Athena, etc.).
• Ability to work independently, meet deadlines, and adapt in a fast-paced environment.
• Experience communicating with patients regarding billing questions and payment options is a plus.
• Strong data entry and documentation skills.
• Proficiency with Microsoft Office Suite, particularly Excel and Outlook.
• Understanding of claim adjudication, payment posting, and denial management processes.

Key Characteristics

• Team Player: Ability to work co-operatively and collaboratively with all levels of employees, management, and external customers to maximize performance and problem-solving
• Integrity & Accountability: Unwavering commitment to doing what is right and upholding ethical standards. Takes ownership of tasks and maintains thorough documentation.
• Detail-Oriented: Accurately manages complex data and payer requirements.
• Persistent and Results-Driven: Follows through on claim resolution with diligence.
• Problem Solver: Applies analytical thinking to resolve billing and denial issues.
• Organized: Manages multiple priorities, deadlines, and payer guidelines efficiently.
• Effective Communicator: Excellent communication skills, both verbal and written. Effectively communicates with internal teams and external payers.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

• Specific vision requirements include the ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus.
• While performing the duties of this job, the employee is regularly required to talk and hear.
• Possess the ability to fulfill any office activities normally expected in an office setting, to include, but not limited to: remaining seated for periods of time to perform computer-based work, participating in filing activity, lifting and carrying office supplies (paper reams, mail, etc.).
• Frequently required to stand, walk, sit, use hands to feel, and reach with hand and arms
• Occasionally lift and/or move up to 20-25 pounds.
• Fine hand manipulation (keyboarding).
• Travel may be required to existing or new OCP locations.