Claims Resolution Specialist 1 - Usftgp Tgmg RCO Back End

The Claims Resolution Specialist I is responsible for the timely and accurate submission, follow‑up, and resolution of third‑party insurance claims to ensure correct reimbursement for services rendered. This position reviews assigned accounts, conducts status inquiries, processes appeals, and determines appropriate actions needed to resolve outstanding balances in accordance with departmental policies, payer guidelines, and regulatory requirements. The Specialist identifies trends impacting claims, assists with clean claim filing, and participates in special projects related to accounts receivable management. The role requires effective communication with payers, attention to detail, and adherence to State, Federal, and carrier regulations to support optimal financial performance for the organization.

Required:

High School Diploma or GED

Work Experience and Additional Information

2 years' experience in physician billing and collection experience

• CPT ICD10 experience
• Experience with EPIC software

Technical Knowledge, Skills, and Abilities

• Understanding of third‑party payer processes, claim workflows, denial reasons, and reimbursement methodologies.
• Knowledge of State and Federal regulations, payer policies, appeal requirements, and compliance standards related to insurance claims.
• Ability to analyze claim issues, identify trends, determine root causes, and recommend solutions that support clean claim submission and reduce denials.
• Strong written and verbal communication skills for contacting payers, preparing appeals, and documenting claim activity accurately and professionally.
• Skills to manage a high‑volume workload, prioritize tasks, meet deadlines, and follow department protocols to ensure timely claim resolution.
• Ability to use billing systems, claim scrubbers, payer portals, and standard office software to review accounts, submit appeals, and track claim status.