Claims Resolution Specialist

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Orthopedic Care Partners

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

💊 Pharmaceuticals

🧘 Wellness

Healthcare Insurance • Pharmaceuticals • Wellness

Orthopedic Care Partners (OCP) is a leading and expansive network of orthopedic care providers, offering a comprehensive growth platform for orthopedic practices across the United States. OCP is known for its superior clinical reputation, scaled infrastructure, and outstanding patient experience. Through strategic partnerships and affiliations, OCP has become one of the largest orthopedic platforms, supported by over 138 physician partners and 42 clinics. They focus on maintaining clinical autonomy for practices, while leveraging shared resources to optimize value-based care. OCP is actively involved in Medicare’s BPCI Program and commercial bundled contracts, capitalizing on data analytics to enhance patient outcomes and reduce costs. Their commitment is to superior clinical outcomes and a great patient experience, while providing a vertically integrated clinical offering and strong physician alignment. The company is well positioned to thrive within the healthcare industry's shifts towards value-based care models.

📋 Description

• The Claims Resolution Specialist plays a critical role in the healthcare revenue cycle by ensuring the accurate and timely submission and resolution of insurance and patient claims. • This position is responsible for claim billing, follow-up, and resolution for government, commercial, and patient payers. • The specialist investigates denied or unpaid claims, performs root cause analysis, documents findings, executes appropriate write-offs or corrections, and ensures compliance with payer guidelines and internal policies. • Submit and track insurance and patient claims for government (e.g., Medicare/Medicaid) and commercial payers. • Perform timely and thorough follow-up on unpaid or denied claims to ensure proper reimbursement. • Conduct root cause analysis on recurring denials or payment issues; escalate trends to management as needed. • Research payer policies and claim-specific requirements to ensure accurate claim resolution. • Process write-offs and adjustments according to established protocols and payer contracts. • Maintain clear, accurate, and thorough documentation of all claim-related activities and communications. • Collaborate with clinical, billing, and coding staff to resolve claim issues and ensure accurate claim submission. • Monitor aging reports and prioritize follow-up efforts based on payer deadlines and financial impact. • Prepare reports and summaries of problem accounts, denial patterns, and process inefficiencies for leadership review. • Assist in implementing process improvements to reduce denials and enhance revenue cycle performance. • Ensure compliance with HIPAA, payer guidelines, and internal billing policies. • Performs other duties as assigned.

🎯 Requirements

• High school diploma or equivalent required; associate's or bachelor's degree in healthcare administration, business, or related field preferred. • 2+ years of experience in medical billing, claims follow-up, or revenue cycle management required, preferably in Orthopedics. • Working knowledge of government and commercial payer guidelines, medical terminology, CPT/ICD-10 coding, and insurance billing practices. • Experience with Electronic Health Record (EHR) and Practice Management systems (e.g., ModMed, Epic, Athena, etc.). • Ability to work independently, meet deadlines, and adapt in a fast-paced environment. • Experience communicating with patients regarding billing questions and payment options is a plus. • Strong data entry and documentation skills. • Proficiency with Microsoft Office Suite, particularly Excel and Outlook. • Understanding of claim adjudication, payment posting, and denial management processes.

🏖️ Benefits

• Remote work • Flexible hours