Claims Resolution Specialist

Position: Claims Resolution SpecialistExemption Status: Non-ExemptReporting Relationship: Billing Lead, Supervisor, or ManagerDirect Reports: NoneWork Environment: Office-BasedPosition SummaryThe Claims Resolution Specialist is responsible for the timely and effective resolution of denied, unpaid, and aging insurance claims to support accurate reimbursement and overall revenue cycle performance. This role serves as a critical liaison between insurance payers, coding staff, patients, and internal departments to identify claim issues, coordinate corrective actions, and pursue reimbursement resolution.The Claims Resolution Specialist researches denials, manages appeals and claim resubmissions, gathers supporting documentation, and identifies trends impacting reimbursement outcomes. This position plays a key role in minimizing preventable revenue loss, improving claim accuracy, and supporting efficient revenue cycle operations.Essential Duties and ResponsibilitiesCore Functional ResponsibilitiesReview denied, rejected, unpaid, and aging claims to identify denial reasons, billing discrepancies, and reimbursement issues.Research claim denials and determine appropriate corrective actions, appeals, or resubmission processes.Forward coding-related denials to the appropriate coding work queue for resolution.Contact insurance companies and payer representatives to resolve denied or unpaid claims and obtain claim processing information.Document all communications, claim actions, and payer interactions accurately within the patient account or applicable system.Gather, review, and submit supporting documentation, including medical records, referrals, authorizations, and appeals documentation according to payer guidelines.Review claim resubmissions to ensure documentation completeness and compliance with payer requirements.Work aging accounts receivable reports to identify reimbursement opportunities and unresolved claims requiring follow-up.Research and locate missing payments, remittance advice forms, or unresolved reimbursement activity.Process first- and second-level appeals in accordance with payer requirements and organizational procedures.Monitor clearinghouse edits, denials, rejections, and billing errors to identify trends and process improvement opportunities.Identify trends related to denials, claim edits, or payer issues and communicate findings to leadership.Track ongoing denial patterns and recommend workflow or process improvements to reduce future denials.Contact patients or referral sources regarding updated insurance information, authorizations, referrals, or missing documentation.Collaboration and CommunicationCollaborate closely with Coder I, Coder II, Coding Supervisor, Coding Manager, and Revenue Cycle leadership to resolve claim issues and improve reimbursement outcomes.Communicate professionally and effectively with insurance companies, patients, providers, coworkers, and external partners.Maintain positive working relationships with insurance payers and internal departments to support timely claims resolution.Participate in departmental initiatives, meetings, training, and special projects as assigned.Compliance and QualityMaintain compliance with Medicare, Medicaid, HIPAA, and payer-specific billing and reimbursement requirements.Ensure confidentiality and appropriate handling of protected health information (PHI).Maintain accurate and timely documentation of all claim resolution activities.Follow organizational policies, departmental procedures, and revenue cycle standards.General ExpectationsMeet established productivity, quality, and timeliness expectations.Demonstrate professionalism, accountability, adaptability, integrity, and sound judgment.Perform other duties as assigned.Success Indicators / Key Performance MetricsAccounts receivable (AR) outcomesCollection and reimbursement resultsDenial resolution effectivenessAppeals and resubmission success ratesTimeliness of claim follow-upReduction in preventable denialsDocumentation accuracyProductivity and aging claim resolution metricsCommunication and collaboration effectivenessTop performers consistently demonstrate persistence in resolving reimbursement issues, strong analytical thinking, excellent communication skills, and the ability to work independently while collaborating effectively with the coding and revenue cycle teams.Required QualificationsEducationHigh school diploma or GED equivalent requiredExperienceOne (1) to two (2) years of medical billing, insurance collections, or healthcare revenue cycle experience requiredExperience working with Medicare, Medicaid, commercial insurance payers, or managed care reimbursement preferredExperience identifying trends related to denials, rejections, edits, and billing errors preferredCertifications/LicensureNone RequiredTechnical SkillsExperience with EHR/EMR systems requiredBasic knowledge of CPT, ICD-10-CM, and HCPCS Level II coding guidelinesBasic understanding of Medical Decision-Making (MDM) and Evaluation & Management (E/M) coding conceptsBasic knowledge of medical terminology and anatomyProficiency with Microsoft Office and practice management systemsStrong documentation and organizational skillsPreferred QualificationsHigh-level understanding of insurance payer reimbursement methodologiesExperience with appeals and denial management processesBilingual English/Spanish preferredExperience working with aging accounts receivable and payer follow-up processWorking Conditions / ADA RequirementsProlonged sitting and computer useFrequent phone communicationFrequent keyboarding and documentation workAbility to maintain concentration while managing multiple claims and deadlinesAbility to communicate effectively verbally and in writingOccasional lifting and movement up to 25 poundsDisclaimerThis job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, or skills required. Responsibilities may change based on organizational needs. #J-18808-Ljbffr