Claims Resolution Specialist

Innovative Hematology, Inc.•Indianapolis, IN

1d•Onsite

About The Position

The Claims Resolution Specialist is a high-impact, project-based role designed to support the organization during a critical phase of revenue cycle transformation. This position offers the opportunity to contribute to enterprise-wide improvements in claims performance while demonstrating capability for potential long-term placement as organizational needs evolve. This role is responsible for the end-to-end resolution of complex, high-dollar hemophilia-related insurance claims that have been denied, underpaid, or delayed by commercial, government, or specialty payers. Serving as both an executional expert and a strategic contributor, the Claims Resolution Specialist leverages deep expertise in payer behavior, billing practices, and appeals strategy to drive claim resolution while identifying systemic trends and opportunities for upstream process improvement. The ideal candidates will bring a strong analytical and problem-solving mindset, with the ability to operate effectively in an evolving environment. This individuals will play a key role in strengthening reimbursement outcomes, reducing denials, and informing the future-state design of revenue cycle operations.

Requirements

High School Diploma or general education degree (GED)
2 - 5 years of experience in medical billing, claims resolution, or revenue cycle operations, with a focus on complex or high-dollar claims
Strong analytical and problem-solving skills, with the ability to identify patterns and root causes
Working knowledge of payer guidelines, appeals processes, and reimbursement methodologies
Ability to navigate ambiguity and contribute in an evolving, fast-paced environment
Strong attention to detail and commitment to accuracy and compliance
Effective communication and collaboration skills across cross-functional teams

Responsibilities

Investigate, analyze, and resolve complex, high-dollar claims that have been denied, underpaid, or delayed, ensuring timely and accurate reimbursement
Review and interpret payer denials to identify root causes (e.g., medical necessity, coding, authorization, coverage limitations, contractual discrepancies)
Prepare and submit comprehensive, payer-specific appeal packages, including clinical documentation, medical necessity justification, and supporting evidence
Interpret and apply payer policies, contracts, and regulatory requirements to support successful claim resolution and escalation strategies
Collaborate cross-functionally with billing, clinical teams, specialty pharmacy, and providers to gather documentation and resolve barriers to payment
Communicate effectively with payer representatives to advocate for reconsideration and drive resolution of complex claims
Maintain accurate and detailed documentation of claim activity, appeal status, and payer interactions within claims management systems
Monitor appeal timelines and ensure compliance with payer and regulatory requirements
Identify denial trends and recurring issues, providing insights and recommendations to improve first-pass claim accuracy and reduce future denials
Contribute to process improvement efforts by partnering with leadership and peers to enhance workflows, reduce rework, and strengthen revenue cycle performance
Ensure compliance with organizational policies, payer requirements, and applicable federal and state regulations
Retrieve, compile, and produce complete medical records and supporting documentation for denied insurance claims and formal appeals
Coordinate the collection of clinical notes, treatment records, laboratory results, authorizations, referrals, physician orders, and other required materials from internal systems, providers, and external partners
Ensure all documentation meets payer-specific requirements, formatting standards, and submission timelines
Verify documentation accuracy, completeness, and consistency prior to submission to Claims Resolution Specialists or upload to payer portals
Prepare and organize appeal packets according to established processes, including indexing, labeling, and secure transmission
Track documentation requests, outstanding items, and submission deadlines to support timely appeal filing
Maintain detailed records of documentation requests and submissions within claims management or document management systems
Communicate effectively with internal departments such as clinical teams, medical records, billing, and pharmacy to obtain required materials
Support audit readiness and compliance by adhering to HIPAA, data privacy policies, and organizational documentation standards