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 <24 hours after readiness).

4. Issue Identification & Communication

• Identify trends in claim holds or delays.
• Communicate recurring issues to leadership or Revenue Cycle Analyst.
• Collaborate with cross-functional teams to resolve barriers to claim submission.

5. Productivity & Performance

• Meet daily/weekly productivity standards for claim submission.
• Maintain high accuracy to support clean claim rate goals.
• Adhere to departmental workflows and documentation standards.
• Maintain regular and predictable attendance.
• Performs other essential duties as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• High School Diploma or equivalent.
• 2+ years of healthcare billing or revenue cycle experience.
• Patient Access / Registration experience preferred.
• Experience working in an EHR system (MEDITECH preferred).
• Experience working in clearinghouse (SSI Preferred).
• Basic understanding of:
• CPT, HCPCS, and ICD-10 coding
• Insurance billing processes
• Claim submission workflows
• 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

• Claim submission turnaround time (< 24 hours from ready status).
• Claims submitted per day (productivity).
• Clean claim rate contribution.
• Work Queue volume and aging.

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.