Claims Resolution Specialist

Duties & responsibilities

• If needed, maximize productivity while performing timely claim follow-up via phone and portals, resolving denials, statusing claims, and drafting appeals.
• Monitor and support BPO agents handling claim statusing and denial resolution, providing daily guidance, productivity monitoring, and alignment with departmental standards.
• Handles high-level escalations for BPO agents.
• Audit BPO claim work for accuracy, completeness, and compliance, identifying training gaps or errors for corrective action.
• Provide training for new hires and lead refresher sessions as needed, supporting BPO development through material and coaching.
• Track BPO KPIs and report underperformance to the Director and Lead to assist in action plans.
• Ensure documentation of all claim-related actions in Jira and CollaborateMD, including updates, payer responses, reimbursement, and escalation notes.
• Maintain up-to-date knowledge of payer requirements, authorization rules, and communication standards to ensure accurate claims processing.
• Engage in team and interdepartmental meetings to troubleshoot issues, identify denial trends, and recommend process improvements.
• Communicate department needs and performance concerns to the Director and lead while supporting accountability and development.
• Participate in the department's L10 meetings, identify and bring issues, and develop and execute To-Dos and quarterly rocks to drive alignment and improvements toward Cipher VTO.
• Performs other related duties as assigned.

Minimum Qualifications

• A High School Diploma or equivalent
• 2 years' professional experience
• 1 year minimum of management and/or healthcare experience
• EOS knowledge/understanding — preferred
• Proficient in Atlassian products (Jira & Confluence) — preferred