Claims Resolution Specialist

OUR COMPANY: Revco Solutions Inc provides best-in-class Revenue Cycle management to Hospital and Physician Service clients.

What We Offer:

• Insurance/401k match
• PTO/Paid holidays
• Referral bonuses

POSITION DESCRIPTION: The Claims Resolution Specialist engages with insurance carriers to negotiate fair reimbursement rates, resolve underpaid or denied claims, and ensure compliance with applicable healthcare regulations, including the No Surprise Act (NSA) when applicable.  

MAJOR AREAS OF RESPONSIBILITY:

· Engage and manage a high volume of out-of-network underpaid claims with payers and third-party pricing vendors to secure favorable reimbursement rates via payor portal, phone and email

· Review and analyze claims against usual, customary, and reasonable (UCR) rates and benchmark data to support maximum reimbursement

· Responsible for contacting health insurance companies to verify patient eligibility, coverage, and benefit details, ensuring accuracy of information.

· Collaborate with internal teams to determine appropriate reimbursement expectations and negotiation strategies

· Track and manage all appeal and negotiation activities, including payer communications, deadlines, and outcomes

· Maintain timely, clear and accurate detailed documentation of all negotiations and claim activity

· Communicate effectively with payers, vendors, and internal stakeholders to drive timely resolution

· Handle escalated or complex claims requiring advanced appeal and negotiation tactics

· Identify trends in payer behavior and reimbursement patterns to support process improvements

· Support appeals and additional follow-up as needed to maximize reimbursement

· Perform other duties as assigned

· Minimum of 3 years of experience in medical billing, insurance follow-up, provider or payor negotiations or revenue cycle operations

· Strong appeal and negotiation experience, preferably with out-of-network claims working with payors, pricing vendors and payer appeal and negotiation processes

· Strong understanding of out-of-network claims processing and reimbursement methodologies

· Familiarity with No Surprises Act (NSA) and Independent Dispute Resolution (IDR) processes preferred

· Ability to read and interpret UB-04s, CMS-1500s, and EOBs, Experience working with CPT/HCPCS/Revenue codes

· Proficiency in claims follow-up, payment posting, and appeals processes

· Strong analytical skills with attention to detail

· Excellent communication and interpersonal skills

· Ability to manage multiple accounts, deadlines, and priorities effectively

· Ability to work independently and stay organized in a remote environment

· Experience with healthcare systems, payor portals and billing platforms

· Strategic negotiation and problem-solving

· Strong organizational and time management skills

· Ability to work independently and collaboratively, Prior remote/work-from-home experience strongly preferred

· Professionalism and confidentiality in handling sensitive information

· Proficiency in Microsoft Office Suite and Teams

· High School Diploma or equivalent required