The Complex Claims Specialist is responsible for reviewing and resolving high-complexity insurance claims, including escalations, disputes, and denied cases. This role involves analyzing medical and billing data, ensuring compliance with policies, and coordinating with multiple stakeholders to achieve accurate and timely claim resolution.
Essential Responsibilities
- Claims Management: Proactively manage workers compensation claims by contacting insurance carriers, adjusters, and utilizing web portals to address outstanding bills.
- Claims Submission & Appeals: Prepare and submit accurate claims while verifying and correcting errors. Compile required documentation for appeals and submit promptly to carriers.
- Billing Accuracy: Update incorrect insurance and patient billing demographics while addressing related issues. Communicate trends or concerns with the team and management.
- Payment Processing: Post payments, document payment records, and resolve issues in a timely manner.
- Document Management: Scan and upload documents and medical records for claims processing and medical records requests.
- Team Collaboration: Alert management of billing trends and contribute to a collaborative team environment.
Key Skills and Qualifications
- Proven experience as a Claims Specialist, Claims Analyst, or similar role (healthcare/RCM preferred)
- Strong background in claims processing, adjudication, or denial management
- Strong experience in workers compensation and no-fault billing, including follow-ups, denials, and appeals.
- Comprehensive knowledge of medical terminology, coding (CPT, ICD-10, modifiers, CCI edits), and bundling rules.
- Proficiency in managing authorizations/referrals, charge entries, payments, and A/R.
- Ability to independently prioritize tasks in a fast-paced environment while maintaining accuracy.
- Familiarity with state workers compensation guidelines, HIPAA regulations, and ethical considerations in handling patient information.
- Hands-on experience with EHR scheduling systems, Excel spreadsheets, and other computerized tools.
- Excellent phone and communication skills to professionally interact with patients, physicians, and insurance carriers.
- Strong negotiation and settlement skills, with the ability to draft written responses effectively.
Traits We Value
- Strong team player with a collaborative mindset and proactive approach.
- Detail-oriented with a focus on data accuracy and quality assurance.
- Commitment to continuous learning and adaptability to change.
- Customer-focused with excellent interpersonal and communication skills.
- Ethical behavior and respect for patient confidentiality.
