Claims Specialist

OneOncology

8d

About The Position

The Claims Specialist works assigned insurance accounts receivable for unpaid, underpaid, and denied Medical Oncology claims. The role reviews accounts to determine why claims were not processed or paid appropriately, researches claim status and payer requirements, and takes appropriate steps to resolve outstanding claims. This includes correcting and resubmitting claims, preparing and following up on payer reconsiderations and appeals, and reviewing reimbursement for underpayments and discrepancies. The specialist documents account activity, meets productivity, quality, and follow-up expectations, escalates reimbursement barriers and recurring issues, and collaborates with revenue-cycle departments while maintaining compliance with HIPAA, organizational policies, payer requirements, and applicable healthcare billing regulations.

Responsibilities

• Work assigned insurance accounts receivable for unpaid, underpaid, and denied Medical Oncology claims.
• Review accounts to determine why claims have not been processed or paid appropriately.
• Research claim status using payer portals, electronic systems, remittance information, EOBs/ERAs, and payer communication.
• Identify and resolve denials involving medical necessity, prior authorization, eligibility and coverage, timely filing, coding and modifier issues, diagnosis-related denials, duplicate claims, coordination of benefits, missing or invalid information, non-covered services, and bundling or reimbursement issues.
• Correct and resubmit claims when appropriate.
• Prepare and submit payer reconsiderations and appeals with applicable supporting documentation.
• Follow up on previously submitted appeals and reconsiderations through final payer determination.
• Review reimbursement to identify potential underpayments and discrepancies between expected and received payment.
• Work Medical Oncology claims involving infusion/administration services and physician-administered medications, including claims utilizing HCPCS J-codes.
• Research payer policies and requirements when necessary to determine the appropriate resolution for a claim.
• Document account activity clearly and accurately, including claim status, denial reason, action taken, payer communication, and next follow-up step.
• Meet established productivity, quality, and account follow-up expectations.
• Escalate payer trends, recurring denials, system issues, or other barriers affecting reimbursement to leadership.
• Collaborate with billing, coding, authorization, clinical, and other revenue-cycle departments as needed to resolve outstanding accounts.
• Identify patterns and root causes contributing to avoidable denials and communicate findings to leadership.
• Maintain compliance with HIPAA, organizational policies, payer requirements, and applicable healthcare billing regulations.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed