Claims Resolution Manager Full Time

About the position

The Claims Resolution Manager is responsible for reviewing, analyzing, and resolving denied or rejected insurance claims by correcting and resubmitting them in a timely and efficient manner, as well as managing the Billing Analyst Team Leads to ensure optimal workflow and performance.

Responsibilities

• Reviewing coding and documentation.
• Identify and resolve coding discrepancies to support accurate billing and revenue integrity.
• Review and analyze denied and rejected claims to determine root cause and required action.
• Research payer policies and guidelines to understand the denial rationale.
• Prepare and submit corrected claims, reconsiderations, and appeal letters with appropriate supporting documentation to ensure maximum reimbursement.
• Collaborate with coders, providers, and clinical staff to resolve documentation issues related to denials.
• Track appeal and resubmission outcomes, maintaining thorough records in the billing system.
• Monitor and follow up on outstanding appeals within payer-specific timelines.
• Escalate unresolved denials or systemic issues to management as needed.
• Work aging reports to ensure timely resolution of unpaid or underpaid claims.
• Communicate with insurance companies by phone, portal, or written correspondence to resolve disputes.
• Identify trends in denials and contribute to process improvement initiatives.
• Review medical records and provider documentation for coding accuracy, completeness, and compliance.
• Abstract and enter coded data into the electronic health record (EHR) or encoder system.
• Stay current on coding updates, NCCI edits, outpatient prospective payment system (OPPS), and CMS regulations.
• Collaborate with clinical and revenue cycle teams to improve documentation quality and reduce coding-related denials.
• Participate in internal and external coding audits and implement corrective action.
• Support charge capture accuracy for inpatient and outpatient services.
• Provide education to clinical staff or peers on documentation improvement opportunities and coding changes.
• Accurately code all Inpatient and Outpatient encounters according to the ICD-10-CM, ICD-10-PCS, CPT-4 Official Guidelines for coding and reporting of physician services.
• Review radiology reports for assignment of appropriate CPT code billing for In and Out Patient scans and procedures.
• Lead the team in serving as the primary point of contact for claims resolution, ensuring timely and accurate handling of issues.
• Reconcile HMG billing.
• Manage HMG coders and Billing Analyst Leads.
• Mentor Billing Analysts.
• Maintain compliance with HIPAA and all coding and billing regulations.

Requirements

• Minimum 3 years of experience in medical billing, claims follow-up, or denial management required.
• Strong knowledge of CPT, ICD-10, and HCPCS codes, understands payer policies, and demonstrates expertise in resolving complex claim issues.
• One year supervisory experience required.
• Experience with EHR/PM systems (e.g., Epic, Athena) and payer portals.

Nice-to-haves

• Revenue Cycle Certification HFMA or other recognized Revenue Cycle Accreditation.
• Coding Certification.

Benefits

• Eligible to receive a Healthcare Financial Management Association (HFMA) membership and access to certification trainings.