The Claims Resolution Specialist manages insurance claims from submission through final resolution. This role focuses on accurate and timely reimbursement by filing claims, performing payer follow-up, validating and resolving denials, and preparing appeals in compliance with payer and regulatory requirements.
Key responsibilities include:
- Filing insurance claims through clearinghouse systems
- Reviewing claim edits and correcting issues before submission
- Uploading or mailing supporting medical records and documentation
- Working payer queues to monitor adjudication and payment
- Contacting insurance carriers for claim status and processing clarification
- Investigating payment discrepancies and overpayment referrals
- Reviewing denial reasons and preparing appeals or reconsiderations
- Tracking appeal outcomes and escalating unresolved cases
- Monitoring denial trends and identifying root causes
- Supporting account cleanup, data entry, and special payer projects
- Maintaining accurate documentation and compliance with HIPAA and payer policies
Requirements & Qualifications
Qualifications
- High school diploma or equivalent required; associate degree or equivalent experience preferred
- 3 to 5 years of experience in a healthcare revenue cycle environment
- Experience with claims submission, payer follow-up, and denial resolution
- Hospital-based billing experience for Medicare and Medicaid plans
- EMR and practice management system experience required; Cerner preferred
Knowledge and skills
- Strong critical thinking and problem-solving skills
- Excellent business writing, grammar, and professional correspondence skills
- Knowledge of 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
- Proficiency with Microsoft Word and Excel
- Strong organizational skills and attention to detail
- Professional customer service skills
Location
Louisiana, US
Employment Type
Not specified
Experience Level
Intermediate Level
Remote work allowed
No
Posted
3 weeks ago