Claim Edits Specialist

Overview

The Claim Edits Specialist plays a vital role in ensuring claims submitted to payers are accurate by meticulously reviewing, validating, and making necessary corrections before submission. This process helps reduce denials and claim rejections effectively.

Key Responsibilities

• Examine claim edits prior to submission and implement corrective measures in accordance with payer and client protocols.
• Monitor trends in claim edits and suggest updates to rules or automation processes for improvement.
• Coordinate with coding and charge entry teams to address discrepancies found in claim edits.
• Maintain prescribed quality and productivity metrics following departmental service level agreements (SLAs).
• Work alongside quality assurance and configuration teams to optimize the efficiency of edit logic.
• Support the preparation of detailed reports and thorough root cause analyses for recurring edit errors.

Qualifications and Experience

• Minimum education is a High School Diploma or GED; Diploma holders in any specialization are eligible to apply.
• Preferred experience includes 2 to 4 years in medical billing and claim resolution.
• Certifications such as AAHAM and/or HFMA are advantageous.
• Prior experience collaborating with offshore teams is desirable.