Claims Resolution Specialist (69288)

VARIETY CARE INC•Oklahoma City, OK

6d•Onsite

About The Position

The Claims Resolution Specialist is responsible for the timely and effective resolution of denied, unpaid, and aging insurance claims to support accurate reimbursement and overall revenue cycle performance. This role serves as a critical liaison between insurance payers, coding staff, patients, and internal departments to identify claim issues, coordinate corrective actions, and pursue reimbursement resolution. The Claims Resolution Specialist researches denials, manages appeals and claim resubmissions, gathers supporting documentation, and identifies trends impacting reimbursement outcomes. This position plays a key role in minimizing preventable revenue loss, improving claim accuracy, and supporting efficient revenue cycle operations.

Requirements

High school diploma or GED equivalent required
One (1) to two (2) years of medical billing, insurance collections, or healthcare revenue cycle experience required
Experience with EHR/EMR systems required
Basic knowledge of CPT, ICD-10-CM, and HCPCS Level II coding guidelines
Basic understanding of Medical Decision-Making (MDM) and Evaluation & Management (E/M) coding concepts
Basic knowledge of medical terminology and anatomy
Proficiency with Microsoft Office and practice management systems
Strong documentation and organizational skills

Nice To Haves

Experience working with Medicare, Medicaid, commercial insurance payers, or managed care reimbursement preferred
Experience identifying trends related to denials, rejections, edits, and billing errors preferred
High-level understanding of insurance payer reimbursement methodologies
Experience with appeals and denial management processes
Bilingual English/Spanish preferred
Experience working with aging accounts receivable and payer follow-up process

Responsibilities

Review denied, rejected, unpaid, and aging claims to identify denial reasons, billing discrepancies, and reimbursement issues.
Research claim denials and determine appropriate corrective actions, appeals, or resubmission processes.
Forward coding-related denials to the appropriate coding work queue for resolution.
Contact insurance companies and payer representatives to resolve denied or unpaid claims and obtain claim processing information.
Document all communications, claim actions, and payer interactions accurately within the patient account or applicable system.
Gather, review, and submit supporting documentation, including medical records, referrals, authorizations, and appeals documentation according to payer guidelines.
Review claim resubmissions to ensure documentation completeness and compliance with payer requirements.
Work aging accounts receivable reports to identify reimbursement opportunities and unresolved claims requiring follow-up.
Research and locate missing payments, remittance advice forms, or unresolved reimbursement activity.
Process first- and second-level appeals in accordance with payer requirements and organizational procedures.
Monitor clearinghouse edits, denials, rejections, and billing errors to identify trends and process improvement opportunities.
Identify trends related to denials, claim edits, or payer issues and communicate findings to leadership.
Track ongoing denial patterns and recommend workflow or process improvements to reduce future denials.
Contact patients or referral sources regarding updated insurance information, authorizations, referrals, or missing documentation.
Collaborate closely with Coder I, Coder II, Coding Supervisor, Coding Manager, and Revenue Cycle leadership to resolve claim issues and improve reimbursement outcomes.
Communicate professionally and effectively with insurance companies, patients, providers, coworkers, and external partners.
Maintain positive working relationships with insurance payers and internal departments to support timely claims resolution.
Participate in departmental initiatives, meetings, training, and special projects as assigned.
Maintain compliance with Medicare, Medicaid, HIPAA, and payer-specific billing and reimbursement requirements.
Ensure confidentiality and appropriate handling of protected health information (PHI).
Maintain accurate and timely documentation of all claim resolution activities.
Follow organizational policies, departmental procedures, and revenue cycle standards.
Meet established productivity, quality, and timeliness expectations.
Demonstrate professionalism, accountability, adaptability, integrity, and sound judgment.
Perform other duties as assigned.