Payer Claims Resolution Specialist – Adjudication & Cash Flow

Description

PURPOSE STATEMENT

The Payer Account Resolution Specialist is responsible for ensuring claims have successfully transferred from the clearing house to the payer for adjudication. Provide any documentation as requested from payers in order to complete adjudication timely. Closely paying attention to timely file requirements. The Payer Account Resolution Specialist ensures claims are being received and adjudicated by payers within their timely filing limit, forming the foundation of the revenue cycle.

This directly impacts cash flow, reduces delays, Timely File Adjustments and supports overall financial performance.

ESSENTIAL FUNCTIONS

• Monitor aging buckets >30 in which claims have been transmitted and have not been adjudicated.
• Contact insurance companies via payer portal, payer chat or phone calls.
• Monitor timely filing limits.
• Document all account activities.
• Locate missing remits and/or payments.
• Resolve payer issue.
• Submit requested documentation.
• Coordinate any claim corrections needed with appropriate department.
• Escalate complex issues.
• Update any identified registration errors.
• Identify opportunities for process improvement.
• Research unpaid claims.
• Communicate with leadership any trends that have been identified.

Requirements

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• High school diploma or equivalent.
• 2+ years of healthcare billing or revenue cycle experience.
• Residency in Missouri or Kansas is required.
• Experience working in an EHR system (MEDITECH preferred).
• Basic understanding of:
• CPT, HCPCS, and ICD-10 coding.
• Insurance billing processes.
• Understanding of Explanation of Benefits.
• Attention to detail and accuracy.
• Time management and ability to meet deadlines.
• Strong organizational skills.
• Effective communication and teamwork.
• Ability to follow standardized workflows.

Performance Metrics

• Keeping AR Days under 40 days.
• Cash meeting or exceeding organization goal.
• Keeping AR under 90 less than 25%.
• Maintain regular and predictable attendance.
• Perform other essential duties as assigned.

PHYSICAL/MENTAL REQUIREMENTS

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.
• Frequently stands, walks, sits and utilizes eye/hand coordination and color definition.
• Occasionally reaches above shoulder, regularly required to lift and/or carry up to 40 lbs.
• Occasionally walks on uneven surfaces.