Claims Resolution Specialist (69288)

Claims Resolution Specialist

Admin (VC) - Oklahoma City, OK

Overview

Position Type: Full Time Job Shift: Day Education Level: High School Travel Percentage: None Category: General Business

Description

Position: Claims Resolution Specialist Exemption Status: Non-Exempt Reporting Relationship: Billing Lead, Supervisor, or Manager Direct Reports: None Work Environment: Office-Based

Position Summary

The 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 Responsibilities

• Review 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 Communication

• Collaborate 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 Quality

• Maintain 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 Expectations

• Meet established productivity, quality, and timeliness expectations.
• Demonstrate professionalism, accountability, adaptability, integrity, and sound judgment.
• Perform other duties as assigned.

Success Indicators / Key Performance Metrics

• Accounts receivable (AR) outcomes
• Collection and reimbursement results
• Denial resolution effectiveness
• Appeals and resubmission success rates
• Timeliness of claim follow-up
• Reduction in preventable denials
• Documentation accuracy
• Productivity and aging claim resolution metrics
• Communication and collaboration effectiveness

Top 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.

Qualifications

Required Qualifications

• Education: High school diploma or GED equivalent required
• Experience: One (1) to two (2) years of medical billing, insurance collections, or healthcare revenue cycle experience required
• Experience working with Medicare, Medicaid, commercial insurance payers, or managed care reimbursement preferred
• Experience identifying trends related to denials, rejections, edits, and billing errors preferred

Certifications/Licensure

• None Required

Technical Skills

• Experience with EHR/EMR systems required
• Basic knowledge of CPT, ICD-10-CM, and HCPCS Level II coding guidelines
• Basic understanding of Medical Decision-Making (MDM) and Evaluation & Management (E/M) coding concepts
• Basic knowledge of medical terminology and anatomy
• Proficiency with Microsoft Office and practice management systems
• Strong documentation and organizational skills

Preferred Qualifications

• High-level understanding of insurance payer reimbursement methodologies
• Experience with appeals and denial management processes
• Bilingual English/Spanish preferred
• Experience working with aging accounts receivable and payer follow-up process

Working Conditions / ADA Requirements

• Prolonged sitting and computer use
• Frequent phone communication
• Frequent keyboarding and documentation work
• Ability to maintain concentration while managing multiple claims and deadlines
• Ability to communicate effectively verbally and in writing
• Occasional lifting and movement up to 25 pounds

Disclaimer

This 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.