Claims Specialist

WHAT WE DO: ACME builds lasting relationships and provides a standard of excellence. Our culture is grounded in honor, integrity, family, and a strong commitment to inspiring hope. ACME is a management service organization that supports a network of healthcare entities across multiple states, delivering managerial and administrative services. These services include corporate administration, recruiting, revenue cycle management, scheduling, accounting, and case management. ACME tailors support services around each organization’s needs. Together, we’re creating more than operational success—we’re building a community of care.

JOB DESCRIPTION: The Claims Specialist plays a critical role in the Revenue Cycle Management (“RCM”) process, managing the full life cycle of claim submission, denial resolution, and payment follow-up to ensure maximum and timely reimbursement for ACME. This individual must possess a deep understanding of billing workflows, medical coding, ledgers, payer requirements, and auditing practices. The Claims Specialist comes into play once claims have been coded and billed, taking ownership of all downstream processes with precision, urgency, and a solution-oriented mindset.

This is a high-performing, cross-functional role that requires frequent communication with internal departments (billing, coding, finance, clinical) and external stakeholders (insurance payers). The ideal candidate will be a strong communicator, highly organized, and driven by results.

KEY RESPONSIBILITIES:

Claims Submission & Lifecycle Management

• Submit and manage claims via electronic and manual submission across commercial and government payers.
• Scrub claims for accuracy, compliance, and completeness using HIPAA 1500 forms—must know this form inside and out.
• Monitor claim acceptance, rejection, and processing statuses daily; initiate corrections promptly when needed.
• Utilize EMR and clearinghouse systems to identify and resolve data integrity issues.
• Perform routine reconciliation of claims activity with Finance to ensure accuracy in revenue recognition.

Denial Management & Audit Ownership

• Investigate, analyze, and resolve claim denials; prepare and submit appeal letters with supporting documentation.
• Identify denial patterns, proactively address root causes, and collaborate with billing/coding teams to implement preventive measures.
• Own post-submission audits, ensuring claim accuracy and compliance with payer guidelines.
• Maintain meticulous documentation of all appeals, corrections, and claim activity.

Payment Follow-Up & Insurance Communication

• Conduct regular, proactive follow-up with insurance payers to expedite claim resolution and payment.
• Develop strong working relationships with payer representatives to facilitate efficient communication and escalations when necessary.
• Keep clear, organized records of payment follow-ups, payer correspondence, and reimbursement outcomes.

Cross-Functional Communication & Collaboration

• Interface with internal departments including Billing, Coding, Clinical, and Finance to resolve complex claim issues.
• Translate technical billing and claims data into clear summaries for team leads and management when needed.
• Participate in RCM team meetings, contributing insights on claim trends and payer behavior.

Documentation and Reporting:

• Maintain accurate and organized records of all billing and claims activities.
• Generate regular reports on claims status, denial rates, and revenue cycle performance and other KPIs.
• Assist with audits and compliance reviews.

Other Duties as assigned.

SKILLS:

• Medical Billing and Coding
• Claims Processing and Management
• Denial Management and Appeals
• Payment Posting and Reconciliation
• Insurance Verification
• EHR/Billing Software Proficiency
• Communication and Customer Service
• Analytical and Problem-Solving Skills
• Knowledge of HIPAA regulations.

QUALIFICATIONS:

· 5 years of hands-on experience in medical claims processing and revenue cycle operations (strongly preferred).

• Knowledge of Medicare, Medicaid, and private insurance regulations, including clinical policy guidelines, LCD/NCD requirements.
• Certified Professional Coder (CPC) certification is a plus.
• Experience with wound care billing is a strong plus.

· Deep understanding of payer guidelines, billing workflows, claim scrubbing, and claim scraping tools.

· Strong working knowledge of CPT, ICD-10, HCPCS codes, modifiers, and medical terminology.

· Familiarity with medical ledgers and routine reconciliation processes.

· Proficiency in Microsoft Office Suite, with emphasis on Excel and Outlook.

· Experience with electronic medical records “EMR” systems and clearinghouse platforms.

· Clinical background or understanding of clinical documentation (preferred).

· Excellent verbal and written communication skills—must be able to explain complex concepts clearly and professionally.

· Highly self-motivated, accountable, and deadline-driven.

· Able to work independently and collaboratively within a fast-paced, high-volume team environment.

Job Type: Full-time

Pay: $50,000.00 - $60,000.00 per year

Benefits:

• 401(k)
• 401(k) 6% Match
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Work Location: In person

Salary : $50,000 - $60,000