Claims & Benefits Resolution Specialist
4255 W Lake Park Blvd West Valley City, UT 84120 US
Job Description
This is an operational “fix-it” position — the manager needs someone who doesn’t just process claims but can find what’s broken and correct it without hand-holding.
Key Responsibilities:
- Claims Audit & Correction
- Perform comprehensive audits on assigned accounts to identify billing, payment, and adjustment errors.
- Correct claim discrepancies within established turnaround times.
- Ensure claim data accuracy, compliant coding, and alignment with the member’s plan benefit.
- Timely & Accurate Claims Processing
- Process claims quickly and accurately according to organizational benchmarks.
- Apply reimbursement rules based on the member’s benefits and plan specifications.
- Validate supporting documentation needed for accurate processing (eligibility, benefits, authorizations, etc.).
- Complex Follow-Up & Dispute Resolution
- Conduct follow-up on delayed, denied, or pended claims; escalate unresolved items as needed.
- Investigate processing delays, missing information, or system errors and implement corrective action.
- Refer cases to clinical management teams when medical review is required to ensure appropriate reimbursement.
- Eligibility, Benefits & Authorization Coordination
- Verify and document member eligibility, benefits coverage, and authorization requirements.
- Identify discrepancies in coverage or authorizations that impact payment determinations.
- Communicate directly with payers or internal departments to resolve missing or inconsistent benefit information.
- Cross-Functional Collaboration
- Work closely with leadership, clinical review staff, and the CBO team to ensure timely resolution of claim issues.
- Participate in problem-solving discussions related to claim trends or systemic issues.
- Support training and onboarding efforts as needed during onsite sessions.
Required Skills & Experience:
- Minimum 2+ years of experience in healthcare revenue cycle, claims processing, eligibility/benefits, or authorizations.
- Strong understanding of payer rules, reimbursement methodologies, and claims adjudication.
- Familiarity with Epic, payer portals, and other claims/RCM systems.
- High accuracy in auditing and error resolution work.
- Experience resolving complex claim issues across multiple systems.
- Ability to work independently, troubleshoot problems, and drive claims to completion
- Strong communication skills for interacting with payers, internal teams, and leadership.
- Comfortable with onsite onboarding and required monthly onsite days.
- Experience working in a Central Business Office or Shared Services model.
- Prior experience supporting Utah-based payer populations or multi-state payer networks.
Job Requirements
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