Claims Resolution Specialist

Claims Resolution Specialist

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.
• Collaborate with coding and clinical teams to obtain information needed for claim resolution.
• Assist with reducing claim holds and billing delays.

Audit & Compliance Support

• Participate in routine claim quality reviews and internal audit activities.
• Ensure claim corrections comply with payer regulations, organizational policies, and billing guidelines.
• Support Revenue Integrity initiatives through accurate claim review and documentation.
• Maintain knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial payer requirements.
• Adhere to HIPAA, CMS, and organizational compliance standards.

Documentation & Reporting

• Maintain detailed documentation of claim investigations, resolutions, payer communications, and follow-up activities.
• Track assigned workloads and resolution outcomes.
• Assist with compiling information for denial trend reporting and operational reviews.
• Provide feedback regarding workflow issues contributing to claim errors or payment delays.
• Assumes other responsibilities as appropriate to the position and organizational needs

Qualifications:

• High School Diploma or equivalent required.
• Associate degree in Healthcare Administration, Medical Billing and Coding, or related field preferred.
• Minimum 2-4 years of experience in medical billing, claims resolution, denial management, accounts receivable, or healthcare revenue cycle operations.
• Working knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial insurance billing requirements.
• Knowledge of CPT, ICD-10-CM, HCPCS, modifiers, and medical terminology.
• Experience researching and resolving denied or rejected claims.
• Strong analytical and critical thinking skills.
• Ability to manage multiple priorities and meet productivity expectations.

Compensation Range:

$28.00 to $35.00 Hourly

All compensation ranges are posted based on internal equity, job requirements, experience, and geographical locations.

Why You'll Love Working Here:

• Amazing work/life balance
• Generous Medical, Dental, Vision, and Prescription benefits (PPO & HMO)
• 401(K) Plan with Employer Matching
• License & Tuition Reimbursements
• Paid Time Off
• Holiday Pay & Floating Holiday
• Employee Perks and Discount Programs
• Supportive environment to help you grow and succeed

Boomerang Healthcare (BHC) is a multidisciplinary and comprehensive team of experienced, committed healthcare providers that treat pain. Our team of doctors approaches each patient with one goal in mind: to help patients return to normal daily activities. We work with our patients to identify the cause of their pain and create a personalized treatment plan, recognizing that no two patients are alike, and neither is their pain. Our providers create a comprehensive care plan, then monitor, manage and coordinate patient access to health services at BHC.

Boomerang Healthcare strives to be a diverse workforce that reflects, at all job levels, the patients we serve. We are an equal opportunity employer. Boomerang Healthcare is committed to compliance with the American Disabilities Act. If you require reasonable accommodation during the application process or have a question regarding an essential job function, please contact us.