Claims Specialist

The Medical Claims Follow-Up Specialist is responsible for managing and resolving outstanding medical claims to ensure timely reimbursement from insurance companies. This role involves reviewing denied or unpaid claims, identifying the reasons for denial or non-payment, and taking appropriate actions to appeal or resubmit claims for processing.

**Key Responsibilities:**

1. Review and analyze denied or unpaid medical claims to determine the reasons for rejection or non-payment.
2. Research and gather necessary documentation and information to support the resubmission or appeal of denied claims.
3. Contact insurance companies to follow up on outstanding claims, inquire about claim status, and resolve issues contributing to claim denials or delays.
4. Identify and address common reasons for claim denials, such as coding errors, eligibility issues, and incomplete documentation.
5. Collaborate with healthcare providers, billing staff, and insurance representatives to resolve claim issues and expedite reimbursement.
6. Prepare and submit appeal letters, claim corrections, and additional documentation as needed to contest claim denials and secure payment.
7. Document all communication and interactions related to claims follow-up in the billing system or electronic health records.
8. Track and monitor the status of outstanding claims, maintain accurate records of follow-up activities, and report on progress to management.
9. Stay updated on changes in insurance regulations, billing guidelines, and coding requirements that may impact claim processing and reimbursement.
10. Provide support and training to billing staff on best practices for claims follow-up and resolution.

**Qualifications:**

- Bachelor’s degree in healthcare administration, business administration, or related field preferred.

- Previous experience working in medical billing, claims processing, or revenue cycle management.

- Knowledge of medical terminology, insurance billing codes (CPT, ICD-10), and insurance reimbursement processes.

- Familiarity with insurance claim forms, electronic claims submission systems, and billing software.

- Strong analytical and problem-solving skills, with the ability to identify issues contributing to claim denials and develop effective resolution strategies.

- Excellent communication and negotiation skills, with the ability to interact professionally with insurance companies, healthcare providers, and internal stakeholders.

- Detail-oriented and organized, with the ability to manage multiple tasks and prioritize work to meet deadlines.

- Proficiency in using computer software for data entry, analysis, and documentation.