Claims Resolution Specialist

Essential Duties And Responsibilities

• File insurance claims through SSI or other clearinghouse systems ensuring timely and accurate submission.
• Review claim edits prior to submission, resolving errors and applying critical thinking to prevent rejections or denials.
• Convert claims to paper format when required by payer guidelines or when electronic submission is unavailable.
• Upload or mail required medical records, forms, and supporting documentation to payers promptly.
• Proactively identify and correct claim issues that may delay reimbursement or result in denials.
• Work assigned payer work queues to ensure prompt adjudication and payment of claims.
• Contact insurance carriers as needed to obtain claim status, clarification of processing issues, or documentation requirements, focusing on utilizing payer portals before calling.
• Investigate and resolve adjudication issues, including payment discrepancies and overpayment referrals.
• Escalate unresolved or complex issues appropriately for further review or payer intervention.
• Accurately document all follow-up actions and communications in the EMR or billing system.
• Review and validate denial reasons against Explanation of Benefits (EOBs).
• Collaborate with HIM and coding teams to ensure coding accuracy and appropriate claim corrections.
• Utilize payer guidelines, NCCI edits, and contract language to research and resolve complex denials.
• Prepare, submit, and track appeals and online reconsiderations in accordance with payer-specific requirements.
• Coordinate with Case Management for clinical reviews or account referrals when necessary.
• Monitor appeal outcomes and ensure timely escalation of unresolved cases.
• Maintain complete, accurate, and timely documentation of all claim research, actions, and outcomes.
• Ensure compliance with HIPAA, payer policies, and organizational standards.
• Meet department performance expectations for quality, productivity, and timeliness.

Denials Management & Appeals

• Prepare, submit, and track appeals and online reconsiderations in accordance with payer-specific requirements.
• Coordinate with Case Management for clinical reviews or account referrals when necessary.
• Monitor appeal outcomes and ensure timely escalation of unresolved cases.

Trend Analysis & Process Improvement

• Monitor denial trends, payment variances, and recurring issues.
• Identify root causes and escalate significant patterns to leadership for payer or process intervention.
• Participate in payer projects, audits, and special initiatives aimed at improving reimbursement and workflow efficiency.

Special Projects & Department Support

• Assist with account clean-up initiatives, data entry, or focused payer projects as assigned.
• Support departmental coverage during periods of high volume or staff absences.
• Participate in training, system updates, and workflow improvement initiatives.