Job Description

Responsibilities

• Review denied, rejected, and unpaid claims to identify the root cause of claim failure and determine appropriate corrective actions.
• Analyze medical records, coding, billing information, and supporting documentation to ensure accuracy and compliance with payer requirements.
• Correct coding, demographic, authorization, eligibility, and billing errors prior to claim resubmission.
• Resubmit claims accurately and within payer-defined timelines to maximize reimbursement and reduce revenue loss.
• Ensure diagnosis and procedure codes are assigned in accordance with ICD-10-CM, CPT, HCPCS, and applicable coding guidelines.
• Investigate payer denials and underpayments, identify trends, and recommend process improvements to reduce recurring issues.
• Collaborate with physicians, coders, billing teams, and revenue cycle staff to obtain clarification and supporting documentation when required.
• Prepare and submit appeal requests for denied claims with appropriate clinical and financial documentation.
• Monitor the status of resubmitted claims and follow up with insurance companies to ensure timely resolution.
• Maintain accurate records of denial reasons, resubmissions, appeals, and claim outcomes.
• Support internal and external audits by providing documentation and explanations related to claim corrections and resubmissions.
• Ensure compliance with healthcare regulations, payer policies, and organizational procedures throughout the resubmission process.
• Generate reports on denial trends, resubmission volumes, recovery rates, and outstanding claims.
• Participate in quality improvement initiatives aimed at enhancing claim acceptance rates and reducing denials.
• Maintain productivity, turnaround time, and accuracy standards established by the organization.
• Stay updated on payer policy changes, coding updates, and reimbursement regulations affecting claim resubmission activities.

Qualifications

• Bachelor’s degree in Health Information Management, Medical Records, Healthcare Administration, Nursing, Pharmacy, or a related healthcare field.
• Professional coding certification such as CPC (Certified Professional Coder)
• Strong knowledge of ICD-10-CM, CPT, and HCPCS coding systems