Claim Status & Rejection Specialist - Hybrid

POSITION SUMMARY
The Claim Status & Rejection Specialist is responsible for resolving all pre-adjudication claim rejections received at the clearinghouse or payer gateway level. This role focuses on identifying, correcting, and resubmitting claims impacted by formatting errors, demographic issues, eligibility-related problems, payer-specific edits, and file-level rejections. The specialist ensures timely resubmission, improves the first-pass clean claim rate, and protects cash flow for pathology billing operations.

KEY RESPONSIBILITIES
• Review and resolve clearinghouse and payer-specific front-end edits.
• Correct and resubmit rejected claims within the payor’s timely guidelines. 
• Identify recurring edit issues and escalate those related to the billing system or workflows.
• Analyze clearinghouse and payer claim status messages.
• Resolve demographic mismatches, eligibility errors and payer ID issues. 
• Ensure corrected claims meet payer-specific coding and billing rules.
• Track patterns in rejections and identify upstream failures.
• Collaborate with Coding, Credentialing, AR, and IT to prevent recurring edits.
• Work claim rejection dashboards daily to ensure timely filing of unsubmitted claims. 
• Use payer portals to validate status and identify required corrections.
• Work closely with Coding to validate CPT/ICD edits.
• Coordinate with Credentialing on payer enrollment issues.
• Collaborate with Claims Processing on submission logic fixes.
• Partner with IT/Systems teams for payer ID updates, formatting changes, and clearinghouse file adjustments.
• Document all corrected claims thoroughly and accurately.
• Report recurring rejection categories to leadership.
• Follow HIPAA, Medicare/Medicaid rules, and payer-specific compliance requirements.

QUALIFICATIONS
Education & Experience
• High school diploma required, associate or bachelor’s preferred.
• 2+ years of RCM experience (pathology/laboratory preferred).
• Experience with clearinghouse workflows (Waystar, Availity, TriZetto, etc.).
• Familiarity with EDI transactions (837, 277CA, 999) strongly preferred.

Technical Skills
• Knowledge of CPT, ICD-10-CM, HCPCS.
• Experience with billing systems (XiFin preferred).
• Strong Excel/reporting skills.

Competencies
• Analytical problem-solving.
• High attention to detail.
• Ability to work high-volume workqueues accurately.
• Strong communication and teamwork.
• Commitment to quality and compliance.
 

The work environment characteristics described here are representative of those and employee encounters while performing the duties of this job. Pathology Billing Services provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, and gender identity. PBS complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This applies to all terms and conditions of employment including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation, and training.

Benefits:

Pathology Billing Services, LLC, offers nationally competitive compensation and benefits. Our benefits program provides a comprehensive array of services to our employees including, but not limited to health insurance (Primarily covered by the company), dental insurance (100% covered by the company) vision insurance, paid time off, retirement contributions (401k), & flexible spending account (FSA).