Provider Reimbursement and Claims Specialist
About The Position
Key Responsibilities Perform manual review and pricing of complex and non-standard claims Interpret hospital, medical group, and provider contracts to determine reimbursement Apply fee schedules, payment methodologies, and regulatory requirements Maintain and manage pend queues and claim inventory Review claims for correct CPT, HCPCS, and ICD-10 coding Validate medical necessity, exclusions, and benefit limitations Investigate and resolve complex claim edits and payment issues Make independent decisions on claim payments and adjustments Act as a Subject Matter Expert (SME) for claims operations Participate in User Acceptance Testing (UAT) for system and contract updates Identify system issues and recommend process improvements Work independently with minimal supervision
Responsibilities
- Perform manual review and pricing of complex and non-standard claims
- Interpret hospital, medical group, and provider contracts to determine reimbursement
- Apply fee schedules, payment methodologies, and regulatory requirements
- Maintain and manage pend queues and claim inventory
- Review claims for correct CPT, HCPCS, and ICD-10 coding
- Validate medical necessity, exclusions, and benefit limitations
- Investigate and resolve complex claim edits and payment issues
- Make independent decisions on claim payments and adjustments
- Act as a Subject Matter Expert (SME) for claims operations
- Participate in User Acceptance Testing (UAT) for system and contract updates
- Identify system issues and recommend process improvements
- Work independently with minimal supervision
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
