Claims Resolution Specialist

Job Description

Job Description

The Claims Resolution Specialist is responsible for the day-to-day investigation and resolution of claim rejections, denials, edits, and reimbursement issues across a multi-site, multi-specialty healthcare organization specializing in pain management, physical medicine, and functional rehabilitation services.

Working closely with the Pre-Billing, Accounts Receivable (A/R), Denials Management, Coding, and Revenue Integrity teams, this position performs detailed claim reviews, researches payer requirements, corrects claim errors, and facilitates timely claim resubmission and payment. The Claims Resolution Specialist serves as a key resource in resolving billing issues and ensuring claims are processed accurately and efficiently.

*This is a remote role. We are only hiring in the following states: AZ, CA, NM, NV, OR, TX and WA.

What you will do:

Claims Resolution & Follow-Up

• 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.

Denial Management Support

• 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.

Pre-Billing & Revenue Cycle Collaboration

• 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.