Claims Resolution Specialist-I

Overview

Process medical claims for large multi-specialty, multi-site healthcare organizations across the United States, following Caduceus standards, client specifics and industry guidelines. The role is fully remote.

What you'll do

• Conduct AR follow-up on front-end scrubs and back-end denials through best practices.
• Scrub charges for submission and launch appeals via the Athena billing platform.
• Review and clear claim edits in the system, including registration, insurance, charge and related issues for high-volume practices.
• Read and interpret EOBs and denials from all insurance carriers, including co-pays, deductibles and co-insurance.
• Process appeals end to end across all payer categories based on insurance denials.
• Differentiate between best practices of appeal, coding review, credentialing review and/or adjustment.
• Contact insurance companies and use web portals and websites for appeal, eligibility, remittance and payment information.
• Report and communicate issues and trends.
• Meet or exceed productivity expectations of a minimum average of 6 denials per hour (approximately 45 per day) while maintaining accuracy and quality standards.
• Perform other duties as assigned.

What you'll need

• 3+ years of experience in claims resolution or medical billing.
• Working knowledge of CPT, ICD-10 and medical terminology.
• Complete understanding of follow-up processes.
• Solid background in AR and overall Revenue Cycle policies and procedures.
• Experience in a medical billing environment where HIPAA and protected health information compliance is strongly enforced.
• Excellent communication skills.
• Excellent systems experience and acuity (EMR and billing and collection systems).
• Proficiency in Microsoft Office Suite, including Word and Excel.
• Bachelor's degree, or medical billing certificate.
• Ability to communicate orally and in writing in a clear and straightforward manner, including with senior leadership and company personnel.
• Ability to plan, manage and lead projects, make decisions and solve problems under pressure, prioritize and organize effectively, show judgment and initiative, and work independently.
• Ability to pass the skills test on the Athena platform and the testing environment for the essential functions.
• Ability to sit for extended periods and to lift and move approximately thirty (30) pounds on a non-routine basis.

Nice to have

• A minimum of 2 years of documented experience on the Athena billing platform (highly preferred).
• Additional EMR experience including Cerner, NextGen and EPIC.
• Formal certification in medical billing (preferred but not required).
• Multi-system and multi-specialty experience.
• Strong business acumen and effective communication skills, including public speaking.

Details

• Location: United States, fully remote.
• Work environment: standard business setting with moderate noise and long periods of computer use.
• Physical requirements: handling (seizing, holding, grasping, fingering objects, tools and controls), close vision, and the ability to receive detailed information through oral and telephonic communication.
• Productivity and quality standards apply, with mastery demonstrated through passing grades in a testing environment.