Claims Specialist

Summary  

The Claims Specialist is responsible for managing the end-to-end claims process for diagnostic laboratory services, ensuring timely and accurate submission, follow-up, and resolution of insurance claims. This role is critical to maximizing reimbursement, reducing denials, and supporting the financial health of the laboratory.  

Job Responsibilities 

• Claims Submission: 
  Prepare, review, and submit claims for diagnostic lab services to commercial and government payers, ensuring compliance with payer guidelines and laboratory policies. 

• Denial Management: 
  Analyze denied claims, identify root causes, and initiate corrective actions including appeals and resubmissions. 

• Follow-Up: 
  Proactively follow up on outstanding claims, monitor aging reports, and communicate with payers to resolve issues and expedite payment. 

• Documentation: 
  Maintain accurate records of claim status, correspondence, and payer responses in the billing system. 

• Collaboration: 
  Work closely with prior authorization, billing, and reimbursement teams to resolve complex claims and support cross-functional RCM initiatives. 

• Compliance: 
  Stay current with payer requirements, coding updates (CPT, ICD-10), and regulatory changes affecting laboratory claims. 

• Reporting: 
  Generate and analyze claims performance reports to identify trends, opportunities for process improvement, and support management decision-making. 

Education, Experience, and Skills  

• Associate’s or Bachelor’s degree in healthcare administration, business, or related field (preferred). 

• 2+ years of experience in medical claims processing, preferably in a diagnostic laboratory or healthcare setting. 

• Strong knowledge of insurance billing, payer requirements, and denial management. 

• Familiarity with laboratory coding (CPT, ICD-10), EOBs, and remittance advice. 

• Proficiency with billing software and Microsoft Office Suite. 

• Excellent attention to detail, organizational, and communication skills. 

• Ability to work independently and collaboratively in a fast-paced environment. 

Work Environment 

This is a fully remote position. The employee will work from a home office or other suitable remote location with reliable high-speed internet access. Work is performed in a climate-controlled environment using standard office equipment including computer, phone, and video conferencing tools. Your standard work schedule and hours will be established in collaboration with your leader and may be adjusted to align with evolving business needs. 
 

Physical Demands 

This is a sedentary role requiring prolonged periods of sitting while working at a computer. Physical demands include: 

• Sitting for extended periods (up to 8 hours per day) 

• Repetitive use of hands and fingers for typing and mouse operation 

• Visual acuity for reading computer screens and documents 

• Ability to communicate effectively via phone and video calls 

• Occasional lifting of up to 10 pounds (office supplies, equipment) 

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. 
 
Acknowledgements 

The above job description is not intended to be an all-inclusive list of duties and standards of the position.  Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor.     

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