Claims Specialist

Wellpath•Franklin, TN

About The Position

The Claims Specialist is responsible for the accurate and timely processing of medical claims in accordance with established rules, coding standards, payer guidelines, and regulatory requirements. The role focuses on reviewing, verifying, and analyzing claim information to determine appropriate payment or denial. This position involves processing new, pended, edited, and returned claims to ensure resolution and completion. The Claims Specialist analyzes and resolves denials, rejections, and payment discrepancies while maintaining quality and turnaround standards. The role also includes communicating with internal teams, providers, payers, and Claims Leadership to support efficient and accurate claim processing.

Requirements

High school diploma or GED required
3-5 years of medical claims processing experience required.
Working knowledge of CPT/HCPCS and ICD-10 coding standards.
Familiarity with CMS guidelines and regulations.
Strong Customer service and communication skills.
Proficiency in the Microsoft Office Suite (Outlook, Word, Excel).
High level of attention to detail with strong organizational skills.
High-volume claims environment.

Responsibilities

Analyze, verify, and process medical claims to determine accurate payment or denial based on established rules and rates.
Review claim data, coding, documentation, edits, and pended reports to ensure completeness and compliance.
Resolve claim denials, rejections, and payment discrepancies through detailed analysis and follow-up.
Communicate with internal teams, providers, payers, and Claims Leadership to address claim-related issues and barriers.
Maintain productivity, quality, and turnaround standards while providing courteous and responsive customer service.