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Cypress HCM · 1 day ago

Provider Reimbursement and Claims Specialist

United States

Contract

Remote

Mid Level

$21.50/hr - $21.50/hr

Cypress HCM is seeking a Provider Reimbursement and Claims Specialist who will serve as a subject matter expert responsible for reviewing, auditing, and pricing claims. The role requires attention to detail and the ability to interpret provider documents to ensure accurate and timely claim payments.

Human ResourcesInformation TechnologyStaffing Agency

Growth Opportunities

Responsibilities

Conduct detailed, manual review and pricing of claims (e.g., out-of-network or non-standard claims) using provider contracts, pricing methodologies, and regulatory mandates where standard auto-adjudication fails

Interpret hospital, medical group and provider contracts with depth to accurately determine payment methodologies, fee schedules, and reimbursement rates for complex claims

Keep the department's claim pend queue inventory current, clearing edit queues by processing claims according to regulatory requirements and plan benefits

Review claims thoroughly for correct CPT/HCPCS, ICD-10 coding, necessity, limitations, and exclusions based on claims policies

Independently investigate and resolve complex claim edits and making informed decisions regarding clearing edits and claim payment

Work independently to resolve difficult or complex transactions, managing smaller claims-related projects from start to finish without supervision

Act as a Subject Matter Expert (SME) for claims, actively identifying system problems, performing User Acceptance Tests (UAT) of new and existing provider contracts, and collaborating with management to enhance claims operations

Qualification

Claims processing systemsCPT/HCPCS codingICD-10 codingProvider contract interpretationMedical claims proceduresData analysisAttention to detailIndependent workTime managementDecision making

Required

Demonstrated experience in manually reviewing and pricing claims, including interpreting provider contracts and fee schedules for non-standard payment methodologies

Hands-on working knowledge and background using claims processing systems

Experience in medical claims procedures, governing rules, and all aspects of pricing and adjudication

Knowledge of CPT/HCPCS, ICD-10 claims coding, and medical terminology

Proven ability to work independently, manage time effectively, and make sound decisions in ambiguous situations

Minimum Education: A high school diploma or equivalent is required