Claims Resolution Specialist

Claims Resolution Specialist

Location: Fully Remote
Schedule: Monday-Friday, Full-Time
Employment Type: Temp-to-Hire
Compensation: $67,000-$75,000 annually

We are seeking a detail-oriented Claims Resolution Specialist to support appeals, reimbursement analysis, payer audits, and operational process improvement initiatives. This role will be responsible for researching and resolving claim discrepancies, reimbursement variances, denials, and payer-related issues while partnering with internal teams and payer representatives to ensure timely and accurate claim outcomes.

The ideal candidate has experience working with healthcare claims, appeals, reimbursement processes, managed care, revenue cycle operations, or payer-related functions and enjoys investigating complex issues and driving solutions.

• Investigate and resolve claim denials, reimbursement discrepancies, payment variances, and payer-related issues.
• Manage pre- and post-audit activities, including appeal research and response support.
• Review payer policies, contracts, reimbursement guidelines, and documentation requirements.
• Analyze claim outcomes and identify root causes of denials, underpayments, and processing issues.
• Research and assist with contract pricing discrepancies and reimbursement variances.
• Track claims, escalations, payer cases, and workflow activity within internal systems and Salesforce.
• Review documentation for accuracy, completeness, and compliance with payer requirements.
• Collaborate with internal stakeholders and payer representatives to resolve complex claim and reimbursement issues.
• Support payer contracting functions, revalidation activities, and documentation reviews.
• Identify trends and opportunities for process improvement, operational efficiencies, and recovery opportunities.
• Maintain compliance with HIPAA, CMS, and applicable state and federal regulations.
• Assist with reporting, audits, workflow optimization, and special projects as assigned.

• Bachelor's degree in Healthcare Administration, Business, Finance, or a related field preferred.
• 3+ years of experience in claims resolution, appeals, denials, reimbursement, payer operations, revenue cycle, managed care, payment integrity, or a related healthcare role.
• Experience working with Medicare, Medicaid, and commercial insurance plans.
• Knowledge of claims processing, reimbursement methodologies, denials management, appeals, and payer requirements.
• Strong analytical and problem-solving skills with the ability to research and resolve complex issues.
• Experience reviewing medical records, claims, remittance advice, contracts, or supporting documentation.
• Proficiency in Microsoft Excel and healthcare-related systems.
• Salesforce experience is highly preferred.
• Excellent communication and collaboration skills.
• Ability to manage multiple priorities in a fast-paced environment.

• Claims Resolution
• Appeals & Grievances
• Revenue Cycle Operations
• Reimbursement Analysis
• Payment Integrity
• Managed Care
• Provider Relations
• Prior Authorizations
• Healthcare Compliance
• Audit Support
• Denials Management

• Competitive salary and comprehensive benefits package.
• Fully remote work environment.
• Medical, dental, and vision coverage.
• Generous paid time off and paid holidays.
• 401(k) with employer contribution.
• Employee ownership and bonus opportunities.
• Wellness and lifestyle reimbursement programs.
• Tuition assistance and professional development support.
• Student loan assistance.
• Technology and remote work reimbursements.
• Collaborative, mission-driven culture with strong opportunities for growth and advancement.

This is an opportunity to join a growing, mission-driven healthcare organization focused on improving access to care and reimbursement outcomes. You'll work alongside a collaborative team dedicated to solving complex claims issues, improving operational processes, and making a meaningful difference in the lives of patients and providers.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.