Account Resolution Specialist II

Overview

This remote position is open to candidates located in the following states: AR, AZ, CA, CO, FL, GA, IA, IL, LA, MO, NC, NE, NJ, NV, OK, PA, SD, TN, TX, VA, WA, and WI.

The role involves managing insurance claims within a healthcare revenue cycle business that handles claim resolution and payment processing for clients. The Account Resolution Specialist II focuses on government payer workflows, particularly Medicare and Worker's Compensation claims, ensuring accurate and timely payment processing.

Responsibilities

• Submit medical claims in compliance with federal, state, and payer-specific requirements.
• Review and correct claim edits, errors, and denials to ensure proper payment.
• Investigate and analyze claim errors and rejections, applying necessary corrections.
• Follow up with payers and collect assigned insurance accounts receivable.
• Stay updated on payer policies and process changes to maintain accurate claims submission and follow-up.
• Evaluate reasons for non-payment and take appropriate actions to resolve claims.
• Prepare and submit first- and second-level appeals with supporting documentation according to payer guidelines and timelines.
• Identify and document coding, clinical, and registration issues for referral to appropriate teams to prevent future denials.
• Escalate stalled claims to payers or leadership as needed.
• Verify and adjust claims to ensure client accounts reflect correct liability and balances.
• Identify payer-specific issues and communicate them to the team and management.
• Achieve 100% of daily productivity goals and maintain a 90% monthly quality assurance score.
• Perform other duties as assigned to support business needs.

Requirements

Qualifications

• High school diploma or equivalent.
• Minimum of 2 years' experience securing medical claim payments from health insurance companies, including managing claim follow-up and appealing denied claims.
• Experience with EMR/EHR systems such as Meditech, Epic, Cerner, Allscripts, Nextgen, or similar platforms.
• Strong knowledge of ICD-10, CPT/HCPCS coding, payer guidelines, and the healthcare revenue cycle process.
• Proficient in Microsoft Office Suite, Teams, and various desktop applications.
• Strong written and verbal communication skills with the ability to advocate effectively with payers.

Knowledge, Skills, and Abilities

• Current knowledge of basic coding principles and payer-specific billing requirements.
• Understanding of healthcare revenue cycle regulations and rules.
• Skilled in investigating medical accounts and validating payments.
• Ability to make decisions and take action independently.
• Quick learner of collaboration and messaging tools.
• Maintain a positive attitude and professional demeanor.
• Take responsibility for the quality and timeliness of work.
• Ability to work independently with minimal oversight.

Client Environment & Role Focus

• Daily use of Cerner CommunityWorks system for claims review, corrections, rebill actions, and account research.
• Heavy focus on government payers, Medicare billing, and Worker's Compensation claims.
• Operations aligned with Eastern Standard Time (EST) business hours.
• Manage complex claim denials and appeals related to medical necessity, coding edits, and prior authorization.
• Meet strict accuracy, productivity, and documentation standards using specialized tools and workflows.

Disclosure

Candidates will undergo a criminal background check and a government exclusion check as part of the hiring process. These screenings verify whether individuals are listed on federal or state exclusion or watchlists to ensure compliance with applicable laws and protect federally funded programs and clients. Consent to these checks is a condition of employment.