Claims Resolution Specialist

Claims Resolution Specialist On‑Site Position Job Summary The Claims Resolution Specialist is responsible for the end‑to‑end management of insurance claims, from submission through final resolution. This role ensures accurate and timely reimbursement by filing claims, performing payer follow‑up, validating and resolving denials, and preparing effective appeals in compliance with payer and regulatory requirements.

The specialist applies critical thinking, strong analytical skills, and detailed research using tools such as payer portals, NCCI edits, contract language, and EMR systems to identify discrepancies, prevent avoidable denials, and optimize revenue outcomes. Exceptional professionalism, business writing skills, and attention to detail are essential to success in this role.

Essential Duties and Responsibilities

Claim Submission & Pre‑Billing Review 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. Payer Follow‑Up & Account Resolution 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. Denials Management & Appeals 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. 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. Documentation & Compliance 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.

Qualifications

Education

& Experience High school diploma or equivalent required; Associate’s degree or equivalent experience preferred. 3–5 years of experience in a healthcare revenue cycle environment, including claims submission, payer follow‑up, and denials resolution. Hospital‑based billing for Medicare/Medicaid plans. EMR/Practice Management system experience required; Cerner experience preferred.

Knowledge, Skills, & Abilities Strong critical thinking and problem‑solving skills with the ability to analyze complex claim and denial scenarios. Advanced proficiency in business writing, grammar, and professional correspondence. Thorough understanding of Explanation of Benefits (EOBs), payer policies, and managed care concepts.

Working knowledge of UB‑04 billing requirements, ICD‑10, CPT/HCPCS coding, and medical terminology. Ability to interpret payer guidelines and contract language and apply findings effectively in appeals. Proficiency in Microsoft Word and Excel and familiarity with EMR/billing systems. Strong organizational skills with attention to detail and accuracy in a high‑volume environment.

Compassionate and professional customer service . Experience in Hospital billing for Medicare and Medicaid plans