Claims Specialist

The Claims Specialist is responsible for reviewing and investigating denied claims from Medicare, commercial payers, and third-party insurers. This role involves preparing and submitting appeals for denied or unpaid medical claims while maintaining strong working relationships with decision makers through professional and responsive service. The position will report directly to the Customer Service Manager.

Job Functions:

• Review denied claims and prepare well-supported appeal letters based on current coding guidelines and clinical criteria
• Track and analyze denial trends to identify root causes and recurring issues
• Monitor payer policy changes and communicate updates to team
• Update account and track customer activity in the department database
• Assist customers with reimbursement strategies and resolve complaints with customized solutions to maximize payments
• Prepare and execute all written correspondence related to claims and appeals
• Always ensure full compliance with HIPPA regulations

Qualifications:

• High School diploma with minimum of 3 yrs. experience handling medical insurance claims appeal
• Strong knowledge of medical terminology, coding guidelines, clinical criteria, and HIPAA regulations
• Excellent investigative, problem-solving, and written communication skills
• Proficient in preparing clear, effective appeal letters
• Strong organizational skills with high attention to detail
• Ability to work independently and manage multiple priorities in a fast-paced environment

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.