Claims Resolution Specialist

The Claims Resolution Specialist is responsible for managing Accounts Receivable and resolving clearinghouse rejections across multiple specialties and clients. This role requires deep end to end revenue cycle knowledge, with a primary focus on claim correction, payer follow up, and driving timely reimbursement.

This individual operates in a high volume, multi client environment and is expected to work independently, identify root causes, and reduce rework through accurate and efficient resolution of claim issues.

Core Responsibilities

• Accounts Receivable Management
• Perform timely follow up on outstanding AR across all aging buckets
• Analyze unpaid claims, identify root causes, and take appropriate action to drive resolution
• Work denials, rejections, and underpayments including corrections, resubmissions, and escalations
• Ensure proper documentation of all actions taken within the practice management system
• Prioritize accounts based on aging, dollar value, and payer specific trends
• Clearinghouse Rejection Resolution
• Review and correct clearinghouse rejections daily to ensure clean claim submission
• Identify trends in rejection types and implement corrective actions to reduce recurrence
• Validate claim data including demographics, coding, modifiers, and payer requirements
• Resubmit corrected claims within defined turnaround times

Claims & Billing Accuracy

• Ensure claims are billed in accordance with payer guidelines and client specific rules
• Validate coding, modifiers, and required data elements prior to submission
• Collaborate with front end and coding teams to resolve upstream issues impacting claim quality

Root Cause Analysis & Process Improvement

• Identify patterns in denials and rejections and escalate systemic issues
• Provide feedback to leadership on workflow gaps, payer trends, and process breakdowns
• Support initiatives focused on reducing AR days, denial rates, and rework
• Cross Functional Collaboration
• Partner with internal teams including QA, Automation, and Client Success to resolve issues
• Communicate effectively with clients when required to clarify billing or payer requirements
• Adapt to multiple EMRs, clearinghouses, and payer systems across clients

Required Qualifications

• Minimum 5 plus years of experience in Revenue Cycle Management with strong focus on AR follow up and claims or rejections
• Proven experience working clearinghouse rejections and payer denials across multiple specialties
• Strong understanding of the full revenue cycle including billing, coding fundamentals, and payer guidelines
• Experience working with multiple EMRs and clearinghouses such as Availity, Change Healthcare, Waystar or similar
• Ability to manage high volume workloads while maintaining accuracy and productivity standards
• Strong analytical and problem-solving skills

Preferred Qualifications

• Multi-specialty experience including radiology, ophthalmology, or surgical practices
• Experience in a multi-client or outsourced RCM environment
• Familiarity with automation tools or workflow optimization initiatives

Key Performance Indicators

• AR resolution rate and reduction in aging
• Clearinghouse rejection turnaround time
• Denial resolution rate and rework reduction
• Productivity and quality accuracy scores
• Contribution to overall cash acceleration and revenue recovery

Work Environment

• Fast-paced, metrics driven environment supporting multiple clients
• Requires adaptability across systems, workflows, and payer requirements
• Strong emphasis on accountability, accuracy, and continuous improvement