Job Description

The role serves as a subject matter expert in claim quality, readiness validation, documentation completeness, and denial prevention. The position directly supports clean-claim performance, reduced rework, and timely revenue realization.

Core Competencies

• Claim Analysis — Evaluates claim data, edits, supporting records, and payer requirements to identify defects and submission risks.

• Revenue Cycle Expertise — Applies healthcare billing, reimbursement, and claim-submission knowledge to resolve complex exceptions.

• Documentation Review — Validates authorizations, prescriptions, medical necessity support, and other required documentation for reimbursement readiness.

• Exception Resolution — Investigates and corrects billing edits, payer rejections, failed transactions, and other claim defects.

• Revenue Protection — Prioritizes accurate, timely resolution of issues that may delay or prevent reimbursement.

• Attention to Detail — Maintains precision while reviewing high-volume claim, documentation, and payer-specific requirements.

• Critical Thinking — Identifies root causes and recurring patterns and recommends practical corrective actions.

• Cross-Functional Collaboration — Partners effectively with Order Management, Billing, Patient Experience, Clinical, Recovery, and related teams.

Essential Duties & Responsibilities

Claim Validation

• Review claims for completeness, accuracy, and submission readiness before billing.

• Validate documentation requirements and identify missing, incomplete, or inconsistent information.

• Verify authorizations, prescriptions, supporting records, medical necessity documentation, and payer-specific billing requirements.

• Confirm claims meet applicable clean-claim and internal quality standards.

• Escalate complex documentation, payer, or claim-readiness issues when additional review is required.

Exception Resolution

• Investigate claim edits, billing exceptions, payer rejections, failed AI transactions, and other submission barriers.

• Correct claim defects and coordinate required updates to support accurate reimbursement.

• Partner with operational teams to obtain missing documentation or resolve workflow dependencies.

• Prioritize exception work based on aging, financial impact, payer requirements, and operational urgency.

• Document resolution activity accurately and consistently within applicable systems and workflows.

Quality Assurance & Denial Prevention

• Conduct detailed claim and documentation audits to identify quality defects before submission.

• Identify recurring trends contributing to denials, rework, payer rejections, or reimbursement delays.

• Support medical necessity validation and documentation-readiness review within established role requirements.

• Recommend corrective actions, process clarifications, or workflow improvements to strengthen claim outcomes.

• Support root-cause investigations and provide subject matter insight on claim-quality trends.

Operational Collaboration

• Work closely with Order Management, Billing, Patient Experience, Clinical Teams, Recovery teams, and other operational partners.

• Communicate documentation deficiencies, claim defects, and required corrections clearly and professionally.

• Support consistent interpretation and application of payer requirements and claim-submission practices.

• Escalate recurring operational issues or systemic defects to the Team Lead or appropriate process owner.

Success in this role will be measured against the following Key Performance Indicators (KPIs) once performance benchmarks and baseline expectations have been established

• Claim Accuracy Rate

• Exception Resolution Rate

• Rework Reduction

• Turnaround Time

• Clean Claim Contribution

Experience & Education

• High school diploma or equivalent required.

• Three (3)+ years of healthcare billing, claims, reimbursement, or revenue cycle experience.

• Working knowledge of payer requirements, claim submission practices, billing edits, and reimbursement workflows.

• Experience reviewing healthcare documentation for completeness and reimbursement readiness.

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

• Ability to manage competing priorities and resolve exceptions within established turnaround expectations.

• Strong written and verbal communication skills with the ability to coordinate effectively across operational teams.

• DME/HME billing or reimbursement experience preferred.

• Denial prevention, claim-quality, or exception-management experience preferred.

• Healthcare reimbursement, billing, coding, or related certification preferred.