Claims Resolution Specialist

Claims Resolution Specialist

This is an on-site position

Job Summary:
The Claims Resolution Specialist plays a key role in ensuring accurate and timely reimbursement by validating denial reasons, researching payer policies, and generating effective appeals. This position requires a critical thinker with strong analytical skills, adept at using tools such as NCCI edits, payer portals, and contract interpretation to overturn denials. The ideal candidate demonstrates exceptional attention to detail, professional communication, and mastery of grammar and business writing.

Essential Duties and Responsibilities

• Review and validate denial reasons against Explanation of Benefits (EOB) and ensure coding accuracy in collaboration with the HIM department.
• Coordinate with Case Management for clinical consultations or account referrals when necessary.
• Research payer guidelines and contract terms to develop compelling appeals, including online reconsiderations.
• Submit appeals in compliance with payer-specific requirements and escalate unresolved cases for further action.
• Investigate and resolve adjudication issues, including contract interpretation and overpayment referrals.
• Utilize NCCI edits and other industry tools to identify and correct claim discrepancies.
• Document all research, actions, and outcomes accurately in the EMR system and route accounts appropriately.
• Monitor denial and payment variance trends; escalate significant patterns to management for payer intervention.
• Participate in payer projects and special initiatives as directed.

Knowledge, Skills, and Abilities

• Strong critical thinking and problem-solving skills with the ability to analyze complex claim issues.
• Advanced proficiency in business writing, grammar, and professional correspondence.
• Understanding of EOBs, managed care contracts, and federal/state requirements.
• Working knowledge of UB-04 billing requirements, ICD-10, HCPCS/CPT coding, and medical terminology.
• Proficiency in Microsoft Office (Word, Excel) and familiarity with EMR systems.
• Ability to interpret contract language and apply it effectively in appeals.

Education and Experience

• Associate’s degree or equivalent experience preferred.
• 3–5 years in a healthcare revenue cycle environment with experience in billing, collections, coding, and insurance appeals. 
• Hospital-based experience is an advantage.
• Cerner experience preferred or relevant aptitude within EMR-based billing applications.

Physical Demands and Work Environment

• Ability to sit and work at a computer for extended periods.
• Work in a collaborative office setting with multiple workstations in close proximity.