Medical and Dental Claims Denial Resolution Specialist; Texas

Position: Medical and Dental Claims Denial Resolution Specialist (Texas) Medical and Dental Claims Denial Resolution Specialist (Texas) Health Drive Corporation is seeking a full‑time Medical and Dental Claims Denial Resolution Specialist to join our team.

Overview

The Medical and Dental Claims Denial Resolution Specialist is responsible for daily review and resolution of insurance claim denials and/or unpaid/incorrectly paid claims with the primary goal to increase cash collections and minimize bad debt write‑offs. Extensive experience working with claim denial resolution for all insurance plan types—including Medicare Part B, Medicare Advantage, Medicaid, Medicaid MCO, Private Insurance, and BCBS—is required. The hourly pay range for this position is $22.00 – $27.00 per hour. We are conveniently located off Route 9 in Framingham, MA, close to routes 90 and 495 in a spacious modern office with a workout center available right in the building. Candidates with significant experience in claim denial resolutions for the Texas insurance plans listed below may be considered for a full‑time remote position in Texas. Aetna Medicare, AARP Medicare, BCBS TX, Cigna Health Spring, Dentaquest, Envolve Vision, Eye Med, Humana Dental, Humana Medicare, Kelsey Care Advantage, March Vision, Medicare TX, Medicaid – TMHP, Molina Health Care of Texas, Molina Medicare/Medicaid (MMP Plan), Provider Partners Health Plan of TX, Pro Care Advantage Medicare, Scott and White Health Plan, Spectera Eye Care, Superior Health Star, Texas Independence Health Plan, United Health Care (Medicare Advantage, Dual and Medicaid plans), Well Care Health and Wellpoint MMP plans. What’s in it for you: PPO Medical, Dental, and Vision Insurance; 401(k) + Company match; Paid Time Off; hybrid schedule opportunity; Verizon Wireless; Dell; and other employee discounts; profit sharing; and employee referral bonuses.

Responsibilities

• Identify, investigate, and follow‑up with insurance plans daily to expedite resolution of denied, incorrectly paid, or unpaid claims.
• Submit corrected claims and appeals online to obtain payment within the insurance plan timely filing and appeal limits.
• Obtain and verify new/corrected insurance information using a clearinghouse or insurance websites prior to rebilling claims to new/updated insurances.
• Document and communicate ongoing denial or incorrect payment issues for a specific insurance plan that require assistance from manager and/or director to help resolve.
• Become the expert on the billing and claim requirements for assigned insurance plans.
• Utilize insurance plan website(s) to check eligibility, claim status, submit online appeals, or provide Explanation of Benefits (EOB’s) / Explanation of Payments (EOP’s) required for processing secondary/tertiary claims.
• Review and resolve over payments, submit requests for insurance to retract their payment, and as needed request refund through automated process in billing system.
• Identify and communicate payment posting issues to cash application team.
• Meet or exceed daily productivity objectives for all assigned duties.
• Respond to email inquiries or Teams chat messages regarding questions/issues with your assigned AR plans within 24 hours.
• Work professionally and cooperatively with facilities, responsible parties, insurance carriers, and all internal and external customers.
• Assist with development of training materials/cheat sheets for assigned insurance plans and actively participate in training of other employees as needed.
• Other duties and tasks assigned or necessary to meet business needs/objectives.

Qualifications

• Prefer minimum of 5 years’ experience in a professional physician multispecialty group managing medical and dental claims denial resolution.
• Extensive knowledge of third‑party billing practices and regulations for insurances in Texas (Medicare Part B, Medicare Advantage, Medicare Supplemental, BCBS, Private Insurance, Medicaid, and Medicaid Managed Care plans).
• Knowledgeable of claim adjustment (CARC) and remark reason codes (RARC) from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of Benefits (EOB’s) / Explanation of Payments (EOP’s), CPT, and ICD

10 codes.

• Highly organized, with excellent attention to detail and…

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