✨ AI Summary
The Submission & Resubmission Officer is responsible for accurately submitting claims and required documentation within established timelines. This role involves reviewing rejected claims, preparing resubmissions, and verifying claim completeness and coding. The officer will monitor claim status, investigate rejections, and maintain accurate records. Key responsibilities include ensuring compliance with payer guidelines, communicating with insurance companies and TPAs, and preparing reports on submission activities and rejection trends. The position requires escalating complex issues and participating in quality improvement initiatives to reduce rejection rates.
Requirements
Requires a Bachelor's degree or diploma in Healthcare Administration, Medical Records, Business Administration, or a related field. Must have 1-3 years of experience in medical claims submission, revenue cycle management, or healthcare operations. Familiarity with insurance claim processing and payer requirements is preferred.
Description
- Submit claims and required documentation accurately and within established timelines.
- Review rejected or denied claims and prepare resubmissions after correcting identified issues.
- Verify claim completeness, coding, and supporting documentation before submission.
- Monitor claim status and follow up on pending, rejected, or returned claims.
- Investigate rejection and denial reasons and coordinate with relevant departments to resolve issues.
- Maintain accurate records of submissions, resubmissions, and claim outcomes.
- Ensure compliance with payer guidelines, company policies, and regulatory requirements.
- Communicate with insurance companies, third-party administrators (TPAs), and internal stakeholders regarding claim status and requirements.
- Prepare daily, weekly, and monthly reports on submission activities, rejection trends, and resubmission performance.
- Escalate complex or recurring issues to the Team Lead or Manager.
- Participate in quality improvement initiatives to reduce rejection rates and improve first-pass claim acceptance.
- Stay updated on changes in payer requirements, coding guidelines, and submission processes.