Claims Documentation Specialist
On-siteDenver, Colorado, United States
Job Summary
Review medical records, claims documentation, and supporting clinical information to validate completeness and alignment with payer medical necessity criteria. Identify missing, incomplete, or inconsistent documentation and communicate specific findings to internal teams through clear written summaries. Maintain confidentiality of patient and claims data while following established guidelines, standard operating procedures, and escalation pathways. Submit medical authorizations based on payer preferences and track follow-up until determination is made. Manage multiple cases and competing priorities to meet defined productivity, accuracy, and quality expectations. Participate in ongoing training and calibration sessions related to payer rules and documentation standards.
Required Qualifications
- High school diploma or equivalent
- Associate degree or relevant healthcare coursework
- Minimum of three years of experience reviewing and interpreting medical records, claims documentation, clinical documentation, insurance documentation, or related healthcare records
- Working knowledge of medical terminology
- Ability to understand documentation related to patient history, diagnoses, treatment plans, orders, and supporting clinical notes
- Strong attention to detail
- Ability to identify documentation gaps, inconsistencies, and discrepancies
- Excellent written and verbal communication skills
- Ability to summarize findings clearly and professionally
- Ability to follow established criteria, checklists, standard procedures, and supervisory direction
- Proficiency with Microsoft Office applications
- Ability to learn claims, documentation, or case management systems
- Ability to manage multiple cases or tasks while meeting established timelines and quality expectations
Desired Qualifications
- Experience reviewing documentation for insurance medical necessity
- Experience with prior authorization
- Experience with utilization review support
- Experience with durable medical equipment
- Experience with home health
- Experience with specialty pharmacy
- Experience with related claims processes
- Experience using electronic medical record systems
- Experience using payer portals
- Experience using claims platforms
- Experience using document management tools
- Familiarity with payer guidelines
- Familiarity with coverage policies
- Familiarity with audit documentation
- Familiarity with medical review workflows
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