Claims Specialist (Agent Role)

The Claims Specialist manages claim appeals and evaluates next steps—whether submitting additional appeals or closing accounts. They prioritize work based on claim complexity, maintain accuracy and compliance, and efficiently process high volumes of low‑balance claims to support timely payments and maximize client revenue recovery.

Responsibilities:

• Prepare and submit clear, well-supported appeals for denied claims using payer rules, contracts, fee schedules, and medical records to secure payment.
• Resolve complex denial issues escalated by Claim Status Specialists, including coding, medical necessity, and policy disputes.
• Investigate payment discrepancies and take corrective steps to recover underpaid amounts.
• Determine whether claims are resolved or need further action, such as additional appeals, escalation, or account closure.
• Close accounts when all collection efforts are completed, ensuring proper documentation...