Claims Resolution Specialist

Western Missouri Medical Center•Warrensburg, MO

2d•Onsite

About The Position

The Claims Resolution Specialist is responsible for the accurate and timely submission of healthcare claims for hospital (facility) and/or physician (professional) services. This role ensures claims are properly prepared, validated, and released from SSI following resolution of all required edits. The Claims Resolution Specialist ensures claims are submitted accurately and promptly, forming the foundation of the revenue cycle. Timely and correct claim submission directly impacts cash flow, reduces delays, and supports overall financial performance. The Claims Resolution Specialist focuses on clean claim submission, working closely with Coding, Patient Access, and Billing QA to ensure compliance with payer requirements and reduce downstream denials.

Requirements

High School Diploma or equivalent.
2+ years of healthcare billing or revenue cycle experience.
Experience working in an EHR system (MEDITECH preferred).
Experience working in clearinghouse (SSI Preferred).
Basic understanding of CPT, HCPCS, and ICD-10 coding
Basic understanding of Insurance billing processes
Basic understanding of Claim submission workflows
Attention to detail and accuracy.
Time Management and ability to meet deadlines.
Strong organizational skills.
Effective communication and teamwork.
Ability to follow standardized workflows.

Nice To Haves

Patient Access / Registration experience preferred.

Responsibilities

Review Errored and Rejected Claims in SSI
Ensure all required elements are complete prior to claim submission: Patient demographics and insurance, Coding (CPT/HCPCS, ICD-10), Modifiers and units, Authorization (if applicable)
Submit claims electronically or via clearinghouse in a timely manner.
Monitor and resolve claims.
Maintain payer enrollment
Verify claims meet CMS billing guidelines, Payer-specific requirements, and Organizational policies
Identify and escalate discrepancies to Manager that relate to Billing QA (for complex edit issues), Coding (for coding clarification), Patient Access (for registration/insurance corrections)
Maintain assigned SSI work queues by working accounts daily, meeting productivity and turnaround targets, and preventing backlog accumulation
Ensure claims are released within established SLA (typically <24 hours after readiness).
Identify trends in claim holds or delays.
Communicate recurring issues to leadership or Revenue Cycle Analyst.
Collaborate with cross-functional teams to resolve barriers to claim submission.
Meet daily/weekly productivity standards for claim submission.
Maintain high accuracy to support clean claim rate goals.
Adhere to departmental workflows and documentation standards.
Maintain regular and predictable attendance.
Performs other essential duties as assigned.