Claims Integrity Specialist

Company Overview

Our client is the national leader in the delivery of superficial radiation therapy services. With partnerships at more than 300 practices across the United States and generating over $130 million in revenue, the company is experiencing rapid growth and offers tremendous opportunities for professional development and career advancement.

Job Summary

We are seeking a detail-oriented and knowledgeable Claims Integrity Specialist to join our dynamic team. This role is responsible for reviewing, analyzing, and resolving denied medical claims to ensure accurate reimbursement and compliance with payer guidelines. The ideal candidate has a strong understanding of medical billing and coding, insurance policies, and the appeals process, along with excellent analytical, technical, and communication skills.

Key Responsibilities

• Review and analyze denied or underpaid claims to determine the root cause and take appropriate corrective action.

• Interpret Explanation of Benefits (EOBs), denial codes, and payer guidelines to identify trends and solutions.

• Research and resolve claim denials through appeals, corrections, and additional documentation, ensuring timely follow-up.

• Submit corrected claims for issues such as missing CPT codes, incorrect provider information, or coding adjustments.

• Apply appropriate CPT modifiers when unbundling office visits with procedures or treatments, in accordance with payer policy.

• Manage day-to-day accounts receivable (A/R) processes, including prioritizing claims from aging reports.

• Use Excel to review, organize, and analyze aging data; filter or create pivot tables to track claim status and trends.

• Utilize EHR/EMR systems, billing platforms, and clearinghouses to process and track claims; troubleshoot clearinghouse rejections or errors.

• Communicate with payers, providers, and internal departments to obtain and clarify necessary information.

• Stay current on changes in medical coding, payer rules, and billing requirements.

• Maintain compliance with HIPAA and all regulatory guidelines.

• Identify and report recurring denial patterns to support process improvement and reduce future denials.

• Contribute to team collaboration and maintain professionalism in all communications.

Required Skills & Qualifications

• Strong understanding of medical billing, ICD-10, CPT, and HCPCS coding.

• 2+ years of experience in medical claims, billing, or denial management.

• Familiarity with CMS-1500 and UB-04 claim forms. 

• Working knowledge of insurance plans (Medicare, Medicaid, commercial payers) and appeals processes.

• Experience interpreting EOBs and working with corrected claims.

• Proficiency with EHR/EMR systems (e.g., Epic, Cerner) and clearinghouse processes.

• Skilled in Microsoft Excel and Office Suite, including sorting, filtering, and analyzing claim data.

• Strong analytical, problem-solving, and organizational skills with attention to detail.

• Excellent written and verbal communication skills.

• Ability to work independently and manage multiple priorities effectively.

• Knowledge of HIPAA regulations and healthcare compliance standards.

Preferred Qualifications

• Certified coder or biller (Dermatology certification preferred).

• Experience in a provider office, oncology, or third-party billing environment.

• Knowledge of insurance verification, benefits, and referrals.

• Demonstrated ability to learn and adapt to new billing or EHR systems quickly.

Benefits & Work Environment

• Competitive salary, commensurate with experience.

• Comprehensive benefits package including medical, dental, vision, life, disability insurance, and 401(k) with company match.

• 15 days PTO in the first year plus 10 paid holidays.

• Hybrid work schedule – work from home two days per week.

• Office with a laid-back, collaborative environment and a casual dress code.

If you are a motivated and skilled Claims Integrity Specialist with a passion for accuracy, compliance, and improving revenue cycle performance, we encourage you to apply and become part of our growing team.