Claim Edits Specialist

Job Summary

• Ensures claims accuracy by reviewing, validating, and correcting claim edits prior to submission to payers, thereby minimizing denials and rejections.

Essential Functions and Tasks

• Analyze pre-submission claim edits and apply corrective actions per payer and client guidelines
• Track claim edit trends and recommend rule updates or automation improvements
• Work with coding and charge entry teams to resolve edit discrepancies.
• Track claim edit trends and recommend rule updates or automation improvements.
• Maintain quality and productivity standards as per departmental SLAs.
• Collaborate with the QA and configuration teams to enhance edit logic efficiency.
• Assist in preparing reports and root cause analyses for repeated edit failures.

Knowledge, Skills, and Abilities

• Strong understanding of payer-specific edits and medical billing workflows
• Experience with claim scrubber tools and billing systems like Athena, Epic, or eCW.
• Knowledge of CPT, ICD-10, and HCPCS coding standards are preferred.
• Become proficient in the use of billing software within 4 weeks and maintain proficiency
• Ability to read, understand and apply state/federal laws, regulations, and policies
• Ability to communicate with diverse personalities in a tactful, mature, and professional manner
• Ability to remain flexible and work within a collaborative and fast-paced environment
• Basic use of a computer, telephone, internet, copier, fax, and scanner
• Basic touch 10 key skills
• Basic Math skills
• Understand and comply with company policies and procedures
• Strong oral, written, and interpersonal communication skills
• Strong time management and organizational skills
• Strong knowledge of Outlook, Word, Excel (pivot tables), and database software skills