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Hospital Claims Specialist
Imagenet LLC. Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, ancillary, Home Health, and SNF claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive experience in adjudicating hospital and facility claims, with a strong understanding of institutional billing, reimbursement methodologies, and compliance with regulatory standards. Proficient in analyzing complex claims and maintaining accurate documentation while ensuring adherence to HIPAA and internal controls.
Highest-signal resume keywords
Claims AdjudicationInstitutional Billing KnowledgeDRG / APR-DRG MethodologiesCPT, HCPCS, ICD-10-CM/PCS ProficiencyAnalytical Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingEligibility VerificationCoding ValidationBenefit CoordinationTimely Filing RulesOverpayment IdentificationProvider Contract InterpretationBundling/Unbundling RulesRevenue Code FamiliarityPayment Integrity Review
Soft Skills
Attention to DetailSound JudgmentClear Communication
Tools & Technologies
Payer PlatformsClaims Adjudication Systems
Industry Keywords
UB-04837I Claim FormatMedicareMedi-CalHome Health ClaimsSNF ClaimsCommercial PlansMedicare AdvantageMedicaid PlansQuality Reviews
About the role
Key responsibilities & impact- Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, ancillary, Home Health, and SNF claims
- Validate member eligibility and cost share, provider affiliation and reimbursement, code validity, dates of service, authorization and referral requirements, and supporting documentation
- Determine whether to pay, deny, adjust, pend, or contest claims, with proper rationale and documentation
- Apply deductibles, copayments, coinsurance, benefit limits, and coordination of benefits correctly
- Identify duplicate billing, coding discrepancies, billing errors, and policy inconsistencies
- Research and resolve pended, high-dollar, high-risk, and complex hospital claims using system data, claim history, itemized bills, clinical records, and authorization details
- Investigate claims requiring independent decision-making
- Identify policy interpretation issues, configuration gaps, and system-related issues; escalate findings and recommendations
- Maintain clear, complete, and audit-ready claim notes
- Ensure adherence to HIPAA, PHI privacy standards, internal controls, and regulatory requirements
- Participate in quality reviews, calibrations, and continuous improvement initiatives
- Support internal and external audits with documentation and explanations of claim decisions
Requirements
What you’ll need- At least 5 years of hands-on experience adjudicating US hospital or facility claims in a payer, TPA, or managed care setting
- Strong working knowledge of institutional billing, including UB-04 and 837I claim formats
- Experience handling inpatient, outpatient, emergency room, Home Health, and SNF claims, including complex cases
- Knowledge of DRG / APR-DRG reimbursement methodologies
- Knowledge of Medicare and Medi-Cal claims processing
- Knowledge of prior authorization and referral requirements
- Knowledge of eligibility and benefits
- Knowledge of timely filing rules
- Knowledge of coordination of benefits
- Knowledge of overpayment and underpayment identification
- Ability to interpret provider contracts and reimbursement terms, payer policies, benefit summaries, and claims processing guidelines
- Strong analytical skills, attention to detail, and sound judgment
- Familiarity with payer platforms and claims adjudication systems
- Clear and confident English communication skills, including the ability to write concise and defensible claim notes
- Strong understanding of CPT, HCPCS, and ICD-10-CM/PCS code sets for hospital claims validation
- Familiarity with revenue codes and UB-04 line-level billing structures
- Working knowledge of bundling/unbundling rules and NCCI edits
- Exposure to DRG grouper logic and case-mix reimbursement principles
- Experience supporting Commercial, Medicare Advantage, or Medicaid plans preferred
- Familiarity with appeals, reconsiderations, or provider dispute resolution preferred
- Working knowledge of DRG and APC concepts, readmission logic, medical necessity indicators, and post-payment review preferred
- Experience in a productivity- and quality-driven BPO or shared services environment preferred
- Experience handling complex denials, pricing logic, payment integrity review, and high-dollar institutional claims highly preferred
Benefits
Comp & perks- DAY 1 HMO Coverage + 1 Free Dependent (Medical & Dental)
- Equipment provided
- Potential WFH set-up based on performance