This role focuses on the accurate and timely processing of insurance claims to support hospital revenue integrity. The specialist is responsible for preparing and submitting claims to third-party payers, identifying and correcting claim edits, and following up on unpaid or rejected claims to secure proper reimbursement. Daily responsibilities include monitoring account statuses, reconciling billing transactions, and using payer portals to verify claim details and resolve issues efficiently.
Key Responsibilities
- Submit clean, error-free claims within established timelines to support prompt payment
- Investigate and resolve claim rejections, denials, and payer-related issues
- Follow up with insurance companies to track unpaid claims and facilitate resolution
- Research and process returned mail and rejected claims to maintain account accuracy
- Ensure compliance with HIPAA and privacy policies when handling protected health information
- Stay current with federal, state, and local regulations affecting hospital billing and reimbursement
- Support Patient Access and Care Management teams in denial analysis and resolution
- Track and report key performance metrics to support department goals
- Participate in training, meetings, and performance improvement efforts as needed
- Maintain productivity and work queue standards in line with operational expectations
Qualifications
A High School diploma or equivalent is required. Preferred qualifications include at least one year of experience in medical billing or a medical office setting, familiarity with medical terminology, business math, and coding systems such as ICD-10 and CPT. Strong attention to detail, organizational skills, and the ability to communicate clearly with patients and colleagues are essential.
Work Environment
This is an onsite position located in West Virginia. The specialist must be comfortable using computers, navigating payer websites, and working within structured workflows to meet productivity and compliance standards. The role requires collaboration with internal teams and consistent communication with external payers.
