Claims Resolution Specialist

Integrated Pain Management Medical Group, Inc.•Walnut Creek, CA

3d•$28 - $35•Remote

About The Position

The Claims Resolution Specialist is responsible for the day-to-day investigation and resolution of claim rejections, denials, edits, and reimbursement issues across a multi-site, multi-specialty healthcare organization specializing in pain management, physical medicine, and functional rehabilitation services. Working closely with the Pre-Billing, Accounts Receivable (A/R), Denials Management, Coding, and Revenue Integrity teams, this position performs detailed claim reviews, researches payer requirements, corrects claim errors, and facilitates timely claim resubmission and payment. The Claims Resolution Specialist serves as a key resource in resolving billing issues and ensuring claims are processed accurately and efficiently.

Requirements

High School Diploma or equivalent required.
Minimum 2-4 years of experience in medical billing, claims resolution, denial management, accounts receivable, or healthcare revenue cycle operations.
Working knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial insurance billing requirements.
Knowledge of CPT, ICD-10-CM, HCPCS, modifiers, and medical terminology.
Experience researching and resolving denied or rejected claims.
Strong analytical and critical thinking skills.
Ability to manage multiple priorities and meet productivity expectations.

Nice To Haves

Associate degree in Healthcare Administration, Medical Billing and Coding, or related field preferred.

Responsibilities

Investigate and resolve claim rejections, denials, and payer edits identified before or after claim submission.
Review claim history, payer correspondence, medical records, authorizations, and supporting documentation to determine the cause of claim issues.
Correct billing, coding, demographic, authorization, and insurance-related claim errors as appropriate.
Process claim corrections, adjustments, resubmissions, and reconsideration requests in accordance with payer guidelines.
Perform payer research and communicate directly with insurance carriers to resolve claim processing issues.
Monitor assigned work queues and ensure timely resolution of outstanding claims.
Escalate complex reimbursement, coding, or compliance issues to senior team members.
Partner with A/R and Denials Management teams to resolve denied and underpaid claims.
Assist in preparing appeal documentation and supporting materials for denied claims.
Identify recurring denial patterns and communicate findings to the Senior Claims Resolution Coordinator.
Maintain accurate documentation of denial resolution activities and payer communications.
Support efforts to reduce preventable denials and improve reimbursement outcomes.
Work closely with the pre-billing team to identify and correct claim issues prior to submission.
Review claims for completeness and compliance with payer billing requirements.
Verify insurance information, authorizations, referrals, diagnosis coding, procedure coding, and modifier usage.
Collaborate with coding and clinical teams to obtain information needed for claim resolution.
Assist with reducing claim holds and billing delays.
Participate in routine claim quality reviews and internal audit activities.
Ensure claim corrections comply with payer regulations, organizational policies, and billing guidelines.
Support Revenue Integrity initiatives through accurate claim review and documentation.
Maintain knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial payer requirements.
Adhere to HIPAA, CMS, and organizational compliance standards.
Maintain detailed documentation of claim investigations, resolutions, payer communications, and follow-up activities.
Track assigned workloads and resolution outcomes.
Assist with compiling information for denial trend reporting and operational reviews.
Provide feedback regarding workflow issues contributing to claim errors or payment delays.
Assumes other responsibilities as appropriate to the position and organizational needs