Claims Resolution Specialist
About The Position
The Claims Resolution Specialist is responsible for accurately and promptly preparing, validating, and submitting healthcare claims for hospital facility and/or physician professional services. The role resolves required edits in SSI before releasing claims and supports the revenue cycle through clean claim submission, timely processing, reduced delays, and compliance with payer requirements. The specialist works closely with Coding, Patient Access, and Billing QA to address issues and reduce downstream denials. The position includes reviewing errored, held, waiting, and rejected claims; confirming that patient demographics, insurance, coding, modifiers, units, and applicable authorizations are complete; and submitting claims electronically or through a clearinghouse. The specialist maintains payer enrollment, verifies compliance with CMS guidelines, payer requirements, and organizational policies, manages assigned work queues, identifies recurring issues, and communicates with leadership and cross-functional teams. Performance is assessed through turnaround time, productivity, clean claim contributions, and work queue volume and aging.
Requirements
- High school diploma or equivalent.
- At least 2 years of healthcare billing or revenue cycle experience.
- Residency in Missouri or Kansas.
- Basic understanding of CPT, HCPCS, and ICD-10 coding.
- Basic understanding of insurance billing processes and claim submission workflows.
- Attention to detail and accuracy.
- Time management skills and ability to meet deadlines.
- Strong organizational skills.
- Effective communication and teamwork.
- Ability to follow standardized workflows.
Nice To Haves
- Patient Access or registration experience.
- Experience with an EHR system; MEDITECH preferred.
- Experience with a clearinghouse; SSI preferred.
Responsibilities
- Review errored and rejected claims in SSI and resolve required edits before submission.
- Verify patient demographics, insurance, coding (CPT/HCPCS and ICD-10), modifiers, units, and applicable authorization are complete.
- Submit claims electronically or via clearinghouse in a timely manner and monitor and resolve claims.
- Maintain payer enrollment.
- Verify claims meet CMS billing guidelines, payer-specific requirements, and organizational policies.
- Escalate complex billing edit issues to Billing QA, coding questions to Coding, and registration or insurance corrections to Patient Access.
- Maintain assigned SSI work queues by working accounts daily, meeting productivity and turnaround targets, and preventing backlog accumulation.
- Release claims within established service-level timelines, typically less than 24 hours after readiness.
- Identify trends in claim holds or delays and communicate recurring issues to leadership or the Revenue Cycle Analyst.
- Collaborate with cross-functional teams to resolve barriers to claim submission.
- Meet daily and weekly productivity standards while maintaining accuracy to support clean claim goals.
- Follow departmental workflows and documentation standards and maintain regular, predictable attendance.
- Perform other essential duties as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
