Description

PURPOSE STATEMENT

The Claims Resolution Specialist is responsible for the accurate and timely submission of healthcare claims for hospital (facility) and/or physician (professional) services. This role ensures claims are properly prepared, validated, and released from SSI following resolution of all required edits. The Claims Resolution Specialist ensures claims are submitted accurately and promptly, forming the foundation of the revenue cycle. Timely and correct claim submission directly impacts cash flow, reduces delays, and supports overall financial performance. The Claims Resolution Specialist focuses on clean claim submission, working closely with Coding, Patient Access, and Billing QA to ensure compliance with payer requirements and reduce downstream denials.

ESSENTIAL FUNCTIONS

Claim Preparation & Submission (Primary Function) Review Errored and Rejected Claims in

SSI:

Ensure all required elements are complete prior to claim submission: Patient demographics and insurance Coding (CPT/HCPCS, ICD-10) Modifiers and units Authorization (if applicable) Submit claims electronically or via clearinghouse in a timely manner. Monitor and resolve claims. Prior to

Claim Submission:

Error, Hold, Wait status

After Claim Transmission:

Rejected Claims Maintain payer enrollment 2. Claim Validation & Compliance Verify claims meet: CMS billing guidelines Payer-specific requirements Organizational policies Identify and escalate discrepancies to Manager that relate to: Billing QA (for complex edit issues) Coding (for coding clarification) Patient Access (for registration/insurance corrections) 3. Work Queue Management Maintain assigned SSI work queues by: Working accounts daily Meeting productivity and turnaround targets Preventing backlog accumulation Ensure claims are released within established SLA (typically