Job Summary
The Medical Claims Specialist is responsible for ensuring timely recovery of outstanding revenue by resolving unpaid and denied medical claims within the healthcare revenue cycle. This role involves end-to-end claims follow-up, including analyzing denials, identifying root causes, and collaborating with internal teams to drive efficient and accurate resolution.
Job Description
- Manage the recovery of outstanding revenue by resolving claim issues across multiple payers.
- Perform end-to-end follow-up on unpaid and denied medical claims to ensure timely resolution.
- Analyze claim rejections and denials, identify root causes, and implement corrective actions to prevent recurrence.
- Maintain up-to-date knowledge of payer policies and insurance coding guidelines to ensure compliance and accuracy.
- Collaborate with Account Managers and the Revenue Cycle Management team to address coding or documentation discrepancies.
- Utilize the system to monitor, escalate, and resolve outstanding claims efficiently.
- Adhere to internal procedures and provide timely updates on claim status and progress.
Screening Criteria
- High school diploma or equivalent combination of education and relevant work experience.
- Minimum of three (3) years of experience in medical claims management or a related healthcare role.
- Stable employment history.
Required Qualifications
- Proficiency in using practice management systems for reporting, documentation, and claims tracking.
- Strong experience in composing appeal letters for denied claims.
- Excellent problem-solving skills with the ability to navigate complex payer requirements.
- Ability to navigate insurance portals to follow up on claims and retrieve necessary information.
- Strong organizational skills with the ability to prioritize tasks and meet deadlines independently.
- Ability to work independently while effectively collaborating with cross-functional teams.
- Strong written and verbal communication skills in English, with the ability to interact professionally with payers, clients, and internal stakeholders.
