About the job
As a Claim Resolution Specialist, you will play a pivotal role in the claims workflow, tasked with submitting appeals to overturn denials and initiate payments. Your responsibilities will include evaluating the necessity for further actions such as additional appeals or account closures. You will prioritize tasks according to the complexity of claims and your workload, ensuring optimal productivity while complying with accuracy standards. By adeptly managing a substantial volume of low-balance claims, you will ensure adherence to compliance, accuracy, and revenue recovery, contributing significantly to the success of our clients.
Key Responsibilities:
- Appeal Submission and Resolution: Craft and present thorough and persuasive appeals for denied claims, leveraging payer guidelines, contracts, fee schedules, and medical records to resolve issues and facilitate payments.
- Escalation Management: Address claims escalated by Claim Status Specialists, effectively resolving intricate denial situations, including coding disputes, medical necessity challenges, or disagreements with payer policies.
- Underpayment Resolution: Review and rectify discrepancies between expected and actual payments, implementing corrective actions to address underpayments.
- Final Determination: Evaluate claims to determine their resolution status or the need for further actions, such as additional appeals, escalation, or account closure based on client specifications.
- Account Closure: Assess and terminate accounts after exhausting all collection efforts, ensuring complete documentation and compliance with client guidelines.
- Account Review Feedback: Identify claims that were incorrectly resolved and return them to the relevant team for further review, correction, or training, thereby enhancing processes.
- Collaboration: Utilize documentation provided by Document Retrieval Specialists and Claim Status Specialists to execute resolution activities effectively.
