Claims Resolution Specialist

Position: Claims Resolution Representative (DME)

Overview

The Claims Resolution Representative is responsible for identifying, correcting, and resolving DME claims that were billed inaccurately due to coding errors, payer discrepancies, or incorrect insurance information. This role ensures claims are properly corrected, rerouted to the appropriate payer, and successfully reimbursed. Complex denials requiring further review are escalated to the Appeals team.

Key Responsibilities

• Analyze claims to determine root cause of misrouting or denial (e.g., incorrect payer, coding errors, eligibility issues)

• Verify and update patient insurance information, including coordination of benefits (COB)

• Review and validate coding accuracy (ICD-10, HCPCS, CPT as applicable)

• Correct claim errors and ensure all required documentation is in place prior to resubmission

• Resubmit corrected claims to the appropriate payer in a timely and accurate manner

• Identify trends or recurring issues in claim errors and contribute to process improvement

• Monitor claim status post-resubmission and follow up on pending or unresolved claims

• Escalate complex denials or unresolved issues to the Appeals team as appropriate

Qualifications

• Previous experience in within DME preferably with Surgical Dressings, Ostomy, Urological, Tracheostomy, etc.)

• Strong understanding of Medicare guidelines, LCDs, and compliance requirements

• Proficiency with medical billing systems and electronic claims submission platforms

• Working knowledge of ICD-10, HCPCS, and CPT coding

• Familiarity with CMS-1500 (professional claims)

• Understanding of payer guidelines, claim frequency codes, and resubmission processes

• High attention to detail with strong organizational and problem-solving skills

• Strong communication skills and ability to work independently and within a team

• Experience with Brightree is highly preferred

• Minimum typing speed of 60 WPM