The specialist will monitor clearinghouse portals to manage and resolve front-end claim rejections through direct payer communication and root cause analysis. They are also responsible for correcting patient demographics and coding errors within EHR systems to ensure successful claim resubmission.
Key Responsibilities
Clearinghouse Monitoring: Daily review and management of clearinghouse portals to capture, sort, and action front-end rejections.
Direct Payer Communication: Contact insurance companies directly via phone or web portals to investigate complex claim rejections, verify active patient eligibility, and check benefit coverage details.
Root Cause Analysis: Investigate why claims were rejected by the clearinghouse or payer, distinguishing between demographic errors, missing insurance details, coding discrepancies, and provider credentialing mismatches.
Claim Correction & Resubmission: Efficiently update and correct patient demographics, insurance policy numbers, CPT/ICD-10 codes, and modifiers within the practice management or EHR software before resubmitting.
Cross-Functional Collaboration: Partner with internal staff and internal medical coders to address data capture errors and help prevent recurring rejections.
Tracking & Reporting: Maintain accurate logs of rejected claims, common rejection trends, and resolution turnaround times, providing visibility to billing management.
Qualifications & Skills
Experience: 1 to 3 years of professional experience in medical billing, revenue cycle operations, or high-volume healthcare administration.
Technical Proficiency: Hands-on familiarity with major clearinghouses and electronic health record (EHR) / practice management software (e.g., Waystar, Cortex, Epic, Athenahealth, eClinicalWorks, NextGen).
Data Accuracy: Exceptional attention to detail with strong alphanumeric data entry and verification skills.
Industry Knowledge: Solid foundational understanding of medical terminology, health insurance structures (Medicare, Medicaid, Commercial), and CMS-1500 claim formats.
Problem-Solving & Communication: Strong telephone etiquette and interpersonal communication skills for effective payer outreach, alongside analytical capability to diagnose billing errors independently.
Shift Flexibility: Proven ability and commitment to reliably work the 6:00 PM to 3:00 AM IST night shift schedule.
Education & Credentials
High school diploma or equivalent required; Associate's degree or general background in healthcare administration or medical billing preferred.
Shift: Night Shift (6:00 PM – 3:00 AM IST)-Remote India
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