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Job details

Claims Resolution Specialist

100 West Lehigh Avenue

Job type:



Job purpose

The primary responsibility of the Claims Resolution Specialist is to effectively resolve outstanding claims for each of the programs within their portfolio using various EHR, databases, or manual processes necessary to submit claims in a timely fashion. The Claims Resolution Specialist is detailed oriented, has the ability to complete tasks with little supervision, and must have extensive analytical skills. The Claims Resolution Specialist will communicate any processing issues to the Billing Manager and/or additional support team member as directed.

Duties and responsibilities

  • Follow-up with payers to resolve all denials, re-submissions, rejections and appeals. 
  • Communicate with insurance companies, program staff and other internal stakeholders to settle billing issues and resolve      patient accounts. 
  • Work delinquent accounts systematically giving priority to aging accounts to resolve balances in a timely manner. 
  • Respond to inquiries or follow up on issues and provide information to resolve outstanding balances. 
  • Partner with Billing Coordinator and program staff to report on open AR balances and ensure a smooth, efficient billing      process.
  • Work closely with Biller and program to create and provide reports to identify billing, accounts receivable, denials and      rejection trends.
  • Maintain documentation of claims resolution process for assigned insurance carriers.
  • Timely communicate denials and billing issues.
  • Confirm that all re-billed services have been successfully transmitted to the funders.
  • Appeal all claims that were denied for not billing within the funders’ required timeframe.
  • Timely resolve any transmission errors (Payor up-front rejections including 277, 999 and TA1)
  • Other duties as assigned
  •   High School Diploma
  • Five years’ experience in a high volume Medical Insurance Billing/AR setting
  • Must have experience with multiple insurance carriers – Particularly PA Medicaid and Medicare
  • Proficiency in Microsoft Office, Excel and Outlook.
  • Must be detailed oriented and must have the ability to complete tasks with little supervision.
  • Experience with Netsmart “Evolv” Suite application is a plus.