US Healthcare / Claims Specialist / RCM / Denial Management

JOB TITLE

Claim Resolution Specialist

JOB PURPOSE

TSI Healthcare specializes in revenue cycle management, offering tailored solutions for healthcare providers to address third-party insurance claims denials, manage underpayments, and optimize reimbursement processes. The Claim Resolution Specialist plays a versatile role in the claims workflow, tasked with submitting appeals to overturn denials and trigger payments or determining whether further action, such as additional appeals or account closure, is required. Specialists in this role may prioritize tasks based on claim complexity and workload, ensuring optimal productivity while maintaining compliance and accuracy. By efficiently processing high volumes of low-balance claims, the specialist ensures compliance, accuracy, and revenue recovery that supports client success.

PRIMARY RESPONSIBILITIES

• Appeal Submission and Resolution: Prepare and submit well-documented and persuasive appeals for denied claims, leveraging payer guidelines, contracts, fee schedules, and medical records to resolve issues and trigger payments.
• Escalation Management: Address claims escalated by Claim Status Specialists, resolving complex denial scenarios such as coding disputes, medical necessity issues, or payer policy conflicts.
• Underpayment Resolution: Investigate and address discrepancies between expected and actual payments, taking corrective action to resolve underpayments.
• Final Determination: Evaluate claims to determine if they are resolved or require further action, such as additional appeals, escalation, or account closure based on client requirements.
• Account Closure: Review and close accounts when collection efforts have been exhausted, ensuring proper documentation and compliance with client guidelines.
• Account Review Feedback: Identify incorrectly resolved claims and return them to the appropriate team for review, correction, or training, contributing to process improvements.
• Collaboration: Utilize documentation provided by Document Retrieval Specialists and Claim Status Specialists to perform resolution activities efficiently

PERSON SPECIFICATION

• High school diploma or equivalent required.
• Minimum of three years of experience in healthcare claims management, denial resolution, or appeal writing. • Experience in high-volume, low-balance claims processing preferred.
• Familiarity with payer-specific policies, reimbursement methodologies, and contract terms.
• Knowledge of coding principles (e.g., CPT, ICD-10, HCPCS) and medical necessity documentation is a plus.

The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities and qualifications may be required and/or assigned as necessary.

This Job Description has been discussed with me and I understand its contents expected of me as an incumbent of this position. This job description is not an exclusive or exhaustive list of all job functions that a team member in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of the company. We provide Equal Employment Opportunity for all individuals regardless of race, color, religion, gender, age, national origin, marital status, sexual orientation, status as a protected veteran, genetic information, status as a qualified individual with a disability and any other basis protected by federal, state or local laws.

For Further Quarries / to Schedule Interview

Contact HR Akila @9632572812

Email: Akila.Ravi@tsico.com