Senior Claims Specialist - Job Description
The Senior Claims Specialist oversees the resolution of complex insurance claims, ensuring accurate reimbursement while supporting the overall revenue cycle for a multi-specialty ophthalmology practice. This role acts as a subject matter expert in ophthalmology billing and coding, payer requirements, and accounts receivable management. The Specialist collaborates closely with providers, coding teams, payment posting staff, and insurance carriers to optimize revenue and maintain compliance with all federal, state, and payer regulations.
Key Responsibilities

Analyze and resolve complex claim denials, underpayments, and billing discrepancies.
Perform detailed follow-up with payers on outstanding accounts receivable to ensure prompt payment.
Research, prepare, and submit appeals for denied, rejected, or partially paid claims.
Identify trends in claim denials and recommend process improvements to minimize future errors.
Monitor aging reports and prioritize high-value and long-outstanding accounts.
Partner with coding, authorization, eligibility, and payment posting teams to address billing issues.
Review Explanation of Benefits (EOBs), Electronic Remittance Advices (ERAs), and payer communications.
Ensure accurate billing for ophthalmology services, including office visits, diagnostic testing, surgical procedures, and injectable medications.
Track and manage appeals through all levels of payer review.
Maintain detailed and accurate documentation of account activity in the practice management system.
Support payer audits, medical record requests, and insurance investigations.
Contribute to month-end reporting and revenue cycle performance initiatives.
Serve as a mentor and resource for Claims Specialists and billing staff.
Participate in process improvement initiatives to enhance collections and reduce accounts receivable days.
Adhere to strict patient confidentiality standards in compliance with HIPAA and organizational policies.
Maintain professionalism and foster positive interactions with patients and colleagues.
Perform additional duties as assigned.

Qualifications

Education: High School Diploma required; Associate's or Bachelor's degree preferred
Experience: Minimum of 5 years in medical billing required; ophthalmology experience preferred
Proven experience submitting claims to HMO/IPA, PPO, Medicare, and Medi-Cal plans
Intermediate computer proficiency, including Microsoft Office, PM/EMR systems (Compulink experience a plus)
Strong written and verbal communication skills in English; bilingual Spanish preferred

Knowledge, Skills, and Abilities

Advanced knowledge of medical billing, claims processing, and accounts receivable management
Strong understanding of Medicare, Medicaid, PPO, HMO, and commercial payer guidelines
Familiarity with ophthalmology-specific billing and coding practices preferred
Working knowledge of CPT, ICD-10, HCPCS codes, modifiers, and NCCI edits
Experience with retina medications (e.g., Avastin, Eylea, Vabysmo, Lucentis, Ozurdex) and related reimbursement processes preferred
Ability to interpret EOBs, contracts, fee schedules, and payer policies
Strong analytical, problem-solving, and organizational skills
Excellent communication and negotiation skills when interacting with insurance carriers
Proficiency with electronic health records (EHR) and practice management systems

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.