Claims Resolution Specialist

Opelousas General Health System; Opelousas (LA); On-site; USD 55,000 - 75,000; Full time

Job summary

Opelousas General Health System is seeking a Claims Resolution Specialist to manage end‑to‑end insurance claims from submission to final resolution. You will ensure timely reimbursement by filing claims, following up with payers, resolving denials, and preparing appeals using payer guidelines and contract language.

Responsibilities include reviewing edits, submitting via SSI or clearinghouses, and documenting all actions in the EMR/billing system.

Qualifications

• High school diploma or equivalent required; Associate’s degree preferred.
• 3–5 years in healthcare revenue cycle with claims submission, payer follow‑up and denials resolution.
• Hospital billing for Medicare/Medicaid plans experience is ideal.
• EMR/Practice Management system experience; Cerner preferred.

Responsibilities

• File insurance claims through SSI or other clearinghouses with timely submission.
• Review claim edits to prevent rejections or denials and correct errors.
• Convert claims to paper format when required by payers.
• Upload or mail required medical records and documentation to payers promptly.
• Identify and correct claim issues that delay reimbursement.
• Work payer work queues to ensure prompt adjudication and payment.
• Contact carriers to obtain claim status and requirements, using payer portals.
• Investigate adjudication issues and escalate complex cases as needed.
• Document follow‑ups in the EMR or billing system.

Skills

Critical thinking

Business writing

EOB understanding

UB-04 ICD-10 CPT

Payer guidelines

MS Word Excel

EMR/billing systems

Attention to detail

Customer service

Education

High school diploma

Associate’s degree preferred

Tools

Cerner

EMR

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Job Summary

The Claims Resolution Specialist is responsible for the end‑to‑end management of insurance claims, from submission through final resolution. This role ensures accurate and timely reimbursement by filing claims, performing payer follow‑up, validating and resolving denials, and preparing effective appeals in compliance with payer and regulatory requirements. The specialist applies critical thinking, strong analytical skills, and detailed research using tools such as payer portals, NCCI edits, contract language, and EMR systems to identify discrepancies, prevent avoidable denials, and optimize revenue outcomes. Exceptional professionalism, business writing skills, and attention to detail are essential to success in this role.

Essential Duties and Responsibilities

• File insurance claims through SSI or other clearinghouse systems ensuring timely and accurate submission.
• Review claim edits prior to submission, resolving errors and applying critical thinking to prevent rejections or denials.
• Convert claims to paper format when required by payer guidelines or when electronic submission is unavailable.
• Upload or mail required medical records, forms, and supporting documentation to payers promptly.
• Proactively identify and correct claim issues that may delay reimbursement or result in denials.
• Work assigned payer work queues to ensure prompt adjudication and payment of claims.
• Contact insurance carriers as needed to obtain claim status, clarification of processing issues, or documentation requirements, focusing on utilizing payer portals before calling.
• Investigate and resolve adjudication issues, including payment discrepancies and overpayment referrals.
• Escalate unresolved or complex issues appropriately for further review or payer intervention.
• Accurately document all follow‑up actions and communications in the EMR or billing system.

Denials Management & Appeals

• Review and validate denial reasons against Explanation of Benefits (EOBs).
• Collaborate with HIM and coding teams to ensure coding accuracy and appropriate claim corrections.
• Utilize payer guidelines, NCCI edits, and contract language to research and resolve complex denials.
• Prepare, submit, and track appeals and online reconsiderations in accordance with payer‑specific requirements.
• Coordinate with Case Management for clinical reviews or account referrals when necessary.
• Monitor appeal outcomes and ensure timely escalation of unresolved cases.

Trend Analysis & Process Improvement

• Monitor denial trends, payment variances, and recurring issues.
• Identify root causes and escalate significant patterns to leadership for payer or process intervention.
• Participate in payer projects, audits, and special initiatives aimed at improving reimbursement and workflow efficiency.

Special Projects & Department Support

• Assist with account clean‑up initiatives, data entry, or focused payer projects as assigned.
• Support departmental coverage during periods of high volume or staff absences.
• Participate in training, system updates, and workflow improvement initiatives.

Documentation & Compliance

• Maintain complete, accurate, and timely documentation of all claim research, actions, and outcomes.
• Ensure compliance with HIPAA, payer policies, and organizational standards.
• Meet department performance expectations for quality, productivity, and timeliness.

Qualifications

Education & Experience

• High school diploma or equivalent required; Associate’s degree or equivalent experience preferred.
• 3–5 years of experience in a healthcare revenue cycle environment, including claims submission, payer follow‑up, and denials resolution.
• Hospital‑based billing for Medicare/Medicaid plans.
• EMR/Practice Management system experience required; Cerner experience preferred.

Knowledge, Skills, & Abilities

• Strong critical thinking and problem‑solving skills with the ability to analyze complex claim and denial scenarios.
• Advanced proficiency in business writing, grammar, and professional correspondence.
• Thorough understanding of Explanation of Benefits (EOBs), payer policies, and managed care concepts.
• Working knowledge of UB‑04 billing requirements, ICD‑10, CPT/HCPCS coding, and medical terminology.
• Ability to interpret payer guidelines and contract language and apply findings effectively in appeals.
• Proficiency in Microsoft Word and Excel and familiarity with EMR/billing systems.
• Strong organizational skills with attention to detail and accuracy in a high‑volume environment.
• Compassionate and professional customer service .
• Experience in Hospital billing for Medicare and Medicaid plans