Claim Status & Rejection Specialist - Hybrid

Pathology Billing Services•Phoenix, AZ

6d•Hybrid

About The Position

The Claim Status & Rejection Specialist is responsible for resolving all pre-adjudication claim rejections received at the clearinghouse or payer gateway level. This role focuses on identifying, correcting, and resubmitting claims impacted by formatting errors, demographic issues, eligibility-related problems, payer-specific edits, and file-level rejections. The specialist ensures timely resubmission, improves the first-pass clean claim rate, and protects cash flow for pathology billing operations.

Requirements

High school diploma required, associate or bachelor's preferred.
2+ years of RCM experience (pathology/laboratory preferred).
Experience with clearinghouse workflows (Waystar, Availity, TriZetto, etc.).
Familiarity with EDI transactions (837, 277CA, 999) strongly preferred.
Knowledge of CPT, ICD-10-CM, HCPCS.
Experience with billing systems (XiFin preferred).
Strong Excel/reporting skills.
Analytical problem-solving.
High attention to detail.
Ability to work high-volume workqueues accurately.
Strong communication and teamwork.
Commitment to quality and compliance.

Responsibilities

Review and resolve clearinghouse and payer-specific front-end edits.
Correct and resubmit rejected claims within the payor's timely guidelines.
Identify recurring edit issues and escalate those related to the billing system or workflows.
Analyze clearinghouse and payer claim status messages.
Resolve demographic mismatches, eligibility errors and payer ID issues.
Ensure corrected claims meet payer-specific coding and billing rules.
Track patterns in rejections and identify upstream failures.
Collaborate with Coding, Credentialing, AR, and IT to prevent recurring edits.
Work claim rejection dashboards daily to ensure timely filing of unsubmitted claims.
Use payer portals to validate status and identify required corrections.
Work closely with Coding to validate CPT/ICD edits.
Coordinate with Credentialing on payer enrollment issues.
Collaborate with Claims Processing on submission logic fixes.
Partner with IT/Systems teams for payer ID updates, formatting changes, and clearinghouse file adjustments.
Document all corrected claims thoroughly and accurately.
Report recurring rejection categories to leadership.
Follow HIPAA, Medicare/Medicaid rules, and payer-specific compliance requirements.