Sr Claims Specialist - Eyecare

Key Responsibilities

• Analyze and resolve complex claim denials, underpayments, and billing discrepancies.
• Perform detailed follow-up with payers on outstanding accounts receivable to ensure prompt payment.
• Research, prepare, and submit appeals for denied, rejected, or partially paid claims.
• Identify trends in claim denials and recommend process improvements to minimize future errors.
• Monitor aging reports and prioritize high-value and long-outstanding accounts.
• Partner with coding, authorization, eligibility, and payment posting teams to address billing issues.
• Review Explanation of Benefits (EOBs), Electronic Remittance Advices (ERAs), and payer communications.
• Ensure accurate billing for ophthalmology services, including office visits, diagnostic testing, surgical procedures, and injectable medications.
• Track and manage appeals through all levels of payer review.
• Maintain detailed and accurate documentation of account activity in the practice management system.
• Serve as a mentor and resource for Claims Specialists and billing staff.
• Participate in process improvement initiatives to enhance collections and reduce accounts receivable days.

Qualifications

• Education: High School Diploma required; Associate’s or Bachelor’s degree preferred
• Experience: Minimum of 5 years in medical billing required; ophthalmology experience preferred
• Proven experience submitting claims to HMO/IPA, PPO, Medicare, and Medi-Cal plans
• Intermediate computer proficiency, including Microsoft Office, PM/EMR systems (Compulink experience a plus)
• Strong written and verbal communication skills in English; bilingual Spanish preferred
• Knowledge, Skills, and Abilities:
  • Advanced knowledge of medical billing, claims processing, and accounts receivable management
  • Strong understanding of Medicare, Medicaid, PPO, HMO, and commercial payer guidelines
  • Familiarity with ophthalmology-specific billing and coding practices preferred
  • Working knowledge of CPT, ICD-10, HCPCS codes, modifiers, and NCCI edits
  • Experience with retina medications (e.g., Avastin, Eylea, Vabysmo, Lucentis, Ozurdex) and related reimbursement processes preferred
  • Ability to interpret EOBs, contracts, fee schedules, and payer policies
  • Strong analytical, problem-solving, and organizational skills
  • Excellent communication and negotiation skills when interacting with insurance carriers
  • Proficiency with electronic health records (EHR) and practice management systems