Orthopedic Care Partners (OCP) is the leading partner for successful, high quality orthopedic surgery practices.
Claims Resolution Specialist
Location
United States
Posted
3 days ago
Salary
0
Seniority
Mid Level
Job Description
Claims Resolution Specialist
Orthopedic Care Partners
• The Claims Resolution Specialist plays a critical role in the healthcare revenue cycle by ensuring the accurate and timely submission and resolution of insurance and patient claims. • This position is responsible for claim billing, follow-up, and resolution for government, commercial, and patient payers. • The specialist investigates denied or unpaid claims, performs root cause analysis, documents findings, executes appropriate write-offs or corrections, and ensures compliance with payer guidelines and internal policies. • Submit and track insurance and patient claims for government (e.g., Medicare/Medicaid) and commercial payers. • Perform timely and thorough follow-up on unpaid or denied claims to ensure proper reimbursement. • Conduct root cause analysis on recurring denials or payment issues; escalate trends to management as needed. • Research payer policies and claim-specific requirements to ensure accurate claim resolution. • Process write-offs and adjustments according to established protocols and payer contracts. • Maintain clear, accurate, and thorough documentation of all claim-related activities and communications. • Collaborate with clinical, billing, and coding staff to resolve claim issues and ensure accurate claim submission. • Monitor aging reports and prioritize follow-up efforts based on payer deadlines and financial impact. • Prepare reports and summaries of problem accounts, denial patterns, and process inefficiencies for leadership review. • Assist in implementing process improvements to reduce denials and enhance revenue cycle performance. • Ensure compliance with HIPAA, payer guidelines, and internal billing policies. • Performs other duties as assigned.
Job Requirements
- High school diploma or equivalent required; associate's or bachelor's degree in healthcare administration, business, or related field preferred.
- 2+ years of experience in medical billing, claims follow-up, or revenue cycle management required, preferably in Orthopedics.
- Working knowledge of government and commercial payer guidelines, medical terminology, CPT/ICD-10 coding, and insurance billing practices.
- Experience with Electronic Health Record (EHR) and Practice Management systems (e.g., ModMed, Epic, Athena, etc.).
- Ability to work independently, meet deadlines, and adapt in a fast-paced environment.
- Experience communicating with patients regarding billing questions and payment options is a plus.
- Strong data entry and documentation skills.
- Proficiency with Microsoft Office Suite, particularly Excel and Outlook.
- Understanding of claim adjudication, payment posting, and denial management processes.
Benefits
- Remote work
- Flexible hours
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