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{Internal} Claims & EDI Specialist

Optima Dermatology

Optima Dermatology

This job is no longer accepting applications

See open jobs at Optima Dermatology.
Portsmouth, NH, USA
Posted on Saturday, January 13, 2024

Claims & EDI Specialist - Accepting Internal Candidates Only

At Optima Dermatology, our mission to revolutionize skin care is made possible by our world class team that is highly engaged, mission-driven, and inspired to set the new standard in dermatology. We are growing rapidly and looking for key team members who believe in our mission and want to make a difference in the lives of our patients. We foster a collaborative environment that is fun and hardworking and promise you will work alongside amazing colleagues you are proud to call your teammates.


Reporting directly to the Revenue Cycle Manager, the Claims and EDI Specialist is responsible for seeking resolution to rejected claims in Clearinghouse (TriZetto) to ensure timely and clean claim submissions

Primary Responsibilities:

  • Run pre-bill queue and verify charges entered for billing/coding specifics
  • Ensures all claims for all payers are submitted electronically, when available
  • Verify doctor participation for all insurances and active location billing
  • Address errors and questions to the office via ModMed tasking system
  • After automated billing and EDI file creation, address any claim production status errors and task situations
  • Submit all EDI files to clearinghouse
  • Verify EDI files have been received for processing at clearinghouse
  • Reviews and works rejected claims to ensure rejection accuracy and meets deadlines
  • Recreate EDI files with corrected claims as necessary, resubmit clean claim file and verify for processing through clearinghouse
  • Create clean claims, void, and correct charges manually as per requested internally from Coding Specialist, Practice Managers or RCM Leadership
  • Utilize resources such as clearinghouse provider portal and clearinghouse contacts to research, escalate and resolve any issues with claim processing and/or rejections
  • Secondary claim files updated with primary EOB information through TriZetto
  • Paper secondary claims printed and submitted with primary EOB within 2 business days
  • EDI files are reviewed daily
  • Create specific EDI files
  • Maintains working day to day knowledge of the practice management system
  • Collaborates with billing team as needed for prompt account resolution
  • Act as a resource to answer questions promptly and accurately including, but not limited to, questions from clearinghouse contacts, management, and payors
  • Identify and communicate patterns and daily trends in clearinghouse/payor rejections and escalate to management for resolution
  • Maintain set standards, metrics and KPIs and ensure individual and departmental goals are met

Position Requirements:

  • High School diploma or equivalent
  • Minimum one (1) year of medical billing background and a consistent record of entering demographics and insurances
  • Capable of adapting to multiple applications of software
  • Skill in exercising initiative, judgment, discretion, and decision-making to achieve business unit objectives
  • Knowledge of reimbursement processes, billing, and accounts receivable
  • Knowledge of CPT and ICD-10 coding
  • Knowledge of payer billing guidelines and policies
  • Ability to work independently and as part of a team
  • Demonstrate excellent written and verbal skills, professional etiquette and courtesy when working with both internal and external customers

This job is no longer accepting applications

See open jobs at Optima Dermatology.