Job Description

Summary:

The Senior Claims Processing Specialist is responsible for the accurate and timely processing of healthcare claims, with a primary focus on resolving clearinghouse rejections and claim edits within the core billing system. This role requires in-depth knowledge of medical billing, coding, payer regulations, and electronic claims submission processes. The Senior Specialist identifies and resolves complex claim issues, provides guidance to junior team members, and ensures claims are submitted cleanly and efficiently to maximize reimbursement.

Key Responsibilities:

Claims Processing:

Review and process healthcare claims according to established policies and procedures. Verify patient demographics, insurance information, and medical coding accuracy. Ensure claims are submitted with all required documentation. Research and resolve claim discrepancies and denials.

Clearinghouse and Claim Edit Management:

Actively monitor clearinghouse rejections and claim edits within the core billing system. Analyze rejection and edit reports to identify root causes of claim issues. Correct errors in patient demographics, insurance information, coding, and billing. Work with clearinghouse representatives to resolve technical issues and optimize claims submission processes. Develop and implement strategies to prevent recurring clearinghouse rejections and claim edits.

Core System Expertise:

Maintain a strong working knowledge of the core billing system and its claims processing functionalities. Utilize the system to research claim status, correct errors, and generate reports. Identify and report system issues to IT or the system vendor. Participate in system testing and upgrades. Stay current on payer-specific billing requirements, coding guidelines, and reimbursement policies. Ensure claims are compliant with all applicable regulations and guidelines. Research and resolve payer-specific claim issues.

Documentation and Reporting:

Document all claim processing activities accurately and thoroughly in the billing system. Prepare reports on claim processing metrics, including rejection rates, denial rates, and turnaround times. Identify trends and patterns in claim issues and propose solutions.

Team Leadership and Mentorship:

Serve as a mentor and resource for junior Claims Processing Specialists. Provide guidance and support to the claims processing team on complex claim issues. Assist in training new team members on claims processing procedures and systems.

Process Improvement:

Identify opportunities to improve claims processing efficiency and accuracy. Participate in process improvement initiatives and projects. Develop and implement best practices for claims processing.

Qualifications, Experience & Skills:

Bachelor's degree in science, Pharma, Nursing, Health Information Management, or a related field preferred. Minimum of 3-5 years of experience in medical claims processing. Strong knowledge of medical billing, coding (CPT, ICD-10), and payer regulations. Experience working with clearing houses and resolving claim rejections and edits. In-depth knowledge of claims processing workflows and procedures. Strong understanding of medical coding and billing guidelines. Excellent analytical and problem-solving abilities. Proficiency in using billing software and clearinghouse portals. Excellent communication and interpersonal skills. Ability to work independently and as part of a team. Excellent organizational and time-management skills.

Preferred Qualifications:

Experience with EPIC preferred but not mandatory Both Hospital and Professional billing experience preferred
Job Type: Full-time

Benefits:

Health insurance Provident Fund
Work Location: In person