Claim Integrity & Exception Specialist

Description

The role serves as a subject matter expert in claim quality, readiness validation, documentation completeness, and denial prevention. The position directly supports clean-claim performance, reduced rework, and timely revenue realization.

The role serves as a subject matter expert in claim quality, readiness validation, documentation completeness, and denial prevention. The position directly supports clean-claim performance, reduced rework, and timely revenue realization.

• Claim Analysis — Evaluates claim data, edits, supporting records, and payer requirements to identify defects and submission risks.
• Revenue Cycle Expertise — Applies healthcare billing, reimbursement, and claim-submission knowledge to resolve complex exceptions.
• Documentation Review — Validates authorizations, prescriptions, medical necessity support, and other required documentation for reimbursement readiness.
• Exception Resolution — Investigates and corrects billing edits, payer rejections, failed transactions, and other claim defects.
• Revenue Protection — Prioritizes accurate, timely resolution of issues that may delay or prevent reimbursement.
• Attention to Detail — Maintains precision while reviewing high-volume claim, documentation, and payer-specific requirements.
• Critical Thinking — Identifies root causes and recurring patterns and recommends practical corrective actions.
• Cross-Functional Collaboration — Partners effectively with Order Management, Billing, Patient Experience, Clinical, Recovery, and related teams.

• Review claims for completeness, accuracy, and submission readiness before billing.
• Validate documentation requirements and identify missing, incomplete, or inconsistent information.
• Verify authorizations, prescriptions, supporting records, medical necessity documentation, and payer-specific billing requirements.
• Confirm claims meet applicable clean-claim and internal quality standards.
• Escalate complex documentation, payer, or claim-readiness issues when additional review is required.

• Investigate claim edits, billing exceptions, payer rejections, failed AI transactions, and other submission barriers.
• Correct claim defects and coordinate required updates to support accurate reimbursement.
• Partner with operational teams to obtain missing documentation or resolve workflow dependencies.
• Prioritize exception work based on aging, financial impact, payer requirements, and operational urgency.
• Document resolution activity accurately and consistently within applicable systems and workflows.

• Conduct detailed claim and documentation audits to identify quality defects before submission.
• Identify recurring trends contributing to denials, rework, payer rejections, or reimbursement delays.
• Support medical necessity validation and documentation-readiness review within established role requirements.
• Recommend corrective actions, process clarifications, or workflow improvements to strengthen claim outcomes.
• Support root-cause investigations and provide subject matter insight on claim-quality trends.

• Work closely with Order Management, Billing, Patient Experience, Clinical Teams, Recovery teams, and other operational partners.
• Communicate documentation deficiencies, claim defects, and required corrections clearly and professionally.
• Support consistent interpretation and application of payer requirements and claim-submission practices.
• Escalate recurring operational issues or systemic defects to the Team Lead or appropriate process owner.