Claims Resolution Specialist (Coder) - 1.0 FTE

Prairie Ridge Health; Town of Columbus (WI); On-site; USD 48,000 - 62,000; Full time

Job summary

Prairie Ridge Health is seeking a Claims Resolution Specialist to join Business Services. This full-time role analyzes and resolves complex insurance denials, collaborates with other teams, and ensures timely claim follow-up across facility and professional billing teams.

You will independently review accounts, apply billing follow-up knowledge, and use multiple systems to resolve claims while supporting revenue cycle workflows and data-driven improvements for the organization.

Qualifications

• High school diploma or equivalent is required.
• CPB through AAPC within 18 months of hire, unless CPC is held.
• Experience with paper and electronic billing for various health insurances.
• Knowledge of CPT/HCPCS and ICD-10 coding.
• Proficient in medical terminology.
• Experience with health insurance and collection techniques.
• Ability to work independently and as part of a team.
• Basic word processing; create professional memos and emails.
• Beginner proficiency with Microsoft Excel; operate relevant software.

Responsibilities

• Research and resolve complex facility and professional insurance denials.
• Communicate with other teams to resolve claims requiring review.
• Review accounts and apply billing follow-up knowledge for maximum reimbursement.
• Use multiple systems to resolve outstanding claims per compliance guidelines.
• Support revenue cycle workflows, charge capture, and work queues.
• Evaluate and trend data for presentation to leadership to optimize revenue cycle.

Skills

Billing follow-up

Interpersonal communication

Research skills

Attention to detail

Education

High school diploma

CPB certification (AAPC)

CPC certification preferred

CPT/HCPCS/ ICD-10 coding experience

Medical terminology knowledge

Health insurance billing & collections

Independent and team-friendly

Basic word processing

Excel (beginner)

Tools

Microsoft Excel

Hospital billing systems

Claims processing software

Job description

Claims Resolution Specialist

Introduction

Prairie Ridge Health is looking for a team member to join Business Services in the role of Claims Resolution Specialist. This position is 1.0 FTE (40 hours per week) and will work Monday - Friday, days. The Claims Resolution Specialist is responsible for researching and resolving complex facility and professional insurance denials and ensures that claims are followed up in a timely manner.

POSITION SUMMARY

• The Claims Resolution Specialist is responsible for researching and resolving complex facility and professional insurance denials and ensures that claims are followed up in a timely manner.
• This position also requires corresponding with other teams on various types of errors to resolve claims needing additional review.
• They independently review accounts and apply billing follow up knowledge required for all insurance payors to ensure proper and maximum reimbursement.
• Uses multiple systems to resolve outstanding claims according to compliance guidelines.
• This role supports the revenue cycle workflows, charge capture, and work queue processes.
• This position will help optimize the Revenue Cycle by evaluating, validating, and trending data for presentation to all levels of the organization.

EDUCATION REQUIREMENTS/LICENSURE/CERTIFICATION/REGISTRATION

• High school diploma (or equivalent) required.
• Certified Professional Biller (CPB) through AAPC within 18 months of hire, unless existing Certified Professional Coder (CPC) is held required.
• Experience with paper and electronic billing for various health insurances, including knowledge of hospital and professional claim forms.
• Experience with revenue codes, CPT, HCPCs, and ICD-10 coding experience.
• Experience with medical terminology.
• Previous experience with health insurance and collection techniques.
• Must possess the ability to work both independently and as a part of a team.
• Credentialed as a Certified Professional Coder (CPC) preferred.
• Must possess the ability to work both independently and as a part of a team.
• Basic word processing proficiency. This includes the ability to: insert tables and bulleted lists; create and utilize form letters; and generate professional-appearing memos and e-mails.
• Beginner proficiency with Microsoft Excel (or other spreadsheet software).
• Must be able to operate computer and software systems in use at Prairie Ridge Health.

CONTRACT AND SHIFT

FTE: 1.0 FTE (40 hours per week)

Shift: Monday - Friday, days.

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.