Claims Research Specialist

Job Description

Job Description

About Us:

Southeastern Retina Associates (SERA), with 21 board-certified ophthalmologists specializing in the treatment and surgery for diseases of the retina, macula and vitreous, is one of the largest remaining physician-owned and independent retina practices in the country, and the most experienced retina team in East Tennessee. Since 1980, SERA has offered the most advanced surgical, injection and medical approaches to patients with all types of retinal conditions, including age-related macular degeneration (AMD), retinal detachment, diabetic retinopathy, macular diseases, retinal vascular diseases, ocular tumors, and ocular trauma. Our compassionate retina specialists combine cutting-edge science with a patient-centric philosophy to achieve the best possible outcomes.

POSITION SUMMARY

Assist with the revenue cycle management of SERA’s Billing Department with a primary focus on the resolution of error, rejected and delinquent claims. This includes, but is not limited to: reviewing claims, researching identified errors, compiling required documentation and preparing the appropriate correspondence to ensure payment.

• Maintain delinquent claims worklist queue and coordinate with fellow Claims Research Specialist.
• Review and research delinquent claims and take all necessary actions and/or corrections to ensure claims payment.
• Processing paper claims and electronically submitted claims including providing additional documentation as required by Carrier to ensure proper payment (Workman’s Compensation, skilled nursing facilities, etc.).
• Electronic data input of secondary claims for carriers requiring on-line claim submission.
• Answer incoming calls from patients, front desk staff and clinical staff as needed helping provide resolutions to current issues.

• Requires in depth understanding of medical reimbursement and coding, including Medicare and Third-Party Insurance guidelines, with the ability to apply knowledge to daily responsibilities.
• Thorough understanding of medical billing, collections and payment posting, revenue cycle, third party payers, Medicare; strong knowledge of TN, GA, VA and Federal payer regulations.
• Working knowledge of CPT and ICD10 codes, HCFA 1500, UB04 claim forms, HIPAA, billing and insurance regulations, medical terminology, insurance benefits and appeal processes.
• Knowledge of business management and basic accounting principles to promote effective communication between Billing and Accounting.
• effective relationships with patients, physicians, staff and other people contacted in the course of the work.
• Proven records of attention to detail and commitment to accuracy in work performed including the ability to enter data accurately in end–user computer applications.

EDUCATION | EXPERIENCE

High school graduate or GED Equivalent.

Minimum 2 years’ experience in a medical billing office with knowledge of medical reimbursement and coding.

The Physical Demands and Work Environment characteristics described below are critical features of this job and are representative of those that must be met by an employee to successfully perform the essential functions. They may be subject to change at any time due to reasonable accommodation or other reasons.

TYPICAL PHYSICAL DEMANDS Work may require sitting for long periods of time; also stooping, bending and stretching for files and supplies. Occasionally lifting files or paper weighing up to 30 pounds. Requires manual dexterity sufficient to operate a keyboard, operates a calculator, telephone, copier and other office equipment as necessary. It is necessary to view and type on computer screens for long periods.

TYPICAL WORKING CONDITIONS Work is performed in an office environment. Work involves frequent contact with staff members and physicians. Work may be stressful at times. Interaction with others is constant and interruptive. The noise level in the work environment is usually moderate. Occasional evening or weekend work as needed.

This description provides only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

It is not intended to be all-inclusive. The employee may be required to perform other reasonably related business duties as assigned.

SERA reserves the right to revise or change job duties and responsibilities as the need arises. This job description does not constitute a written or implied contract of employment.

HIPAA: All employees are required to adhere to the SERA privacy practices as documented in the SERA Employee Handbook and all SERA HIPAA policies and procedures. Failure to comply may result in disciplinary action ranging from a warning to termination depending on the level of violation.

This is not just a job—it’s a career opportunity. We are looking for individuals who want to grow, learn, and stay. We invest in our people with structured training, support, and advancement paths. This is an ideal opportunity for someone who wants to build a future in healthcare, not just collect a paycheck.

If you’ve moved frequently between jobs or are unsure about committing to a long-term position, this may not be the right fit. But if you’re eager to join a team where you can plant roots, develop skills, and make a difference, we’d love to meet you.