Claim specialist Jobs in Westminster, CO

Revenue Operations Manager

This position manages revenue operations work queues, establishes clean-claim controls, monitors first-pass acceptance and rejection trends, and coordinates corrective actions when billing or documentation defects to place revenue at risk. The Manager partners closely with Order Management, Revenue Recovery, Payment Integrity & Revenue Performance, Revenue Systems Strategy & Business Optimization, Finance, Payer Relations, Compliance, Information Technology, and external vendors.

Core Competencies

• Revenue Operations Leadership: Leads claim creation, validation, submission readiness, and clean-claim workflows with clear priorities, ownership, service expectations, and accountability for quality, timeliness, and results.
• Claims, Billing, and Clean-Claim Expertise: Applies strong knowledge of healthcare claims, payer requirements, billing rules, EDI workflows, and timely filing to ensure claims are complete, accurate, compliant, and submission-ready.
• Quality, Risk, and Work-Queue Management: Maintains disciplined oversight of work queues, aging, quality controls, and escalations to reduce billing defects, protect timely filing, and minimize financial exposure.
• Root-Cause Analysis and Process Improvement: Identifies recurring defects, rejection patterns, and workflow gaps and partners across teams to implement corrective actions and sustainable process improvements.
• Data-Driven Decision-Making: Uses operational, quality, productivity, aging, and financial data to identify trends, prioritize work, evaluate performance, and support informed decisions.
• Cross-Functional Collaboration and Communication: Partners effectively across operational, financial, technical, compliance, and payer-facing teams to resolve issues, strengthen handoffs, and maintain clear accountability.
• Coaching, Accountability, and Follow-Through: Sets clear expectations and provides consistent coaching, feedback, and development while ensuring performance gaps, commitments, and corrective actions reach resolution.

Essential Duties & Responsibilities

Revenue Operations Leadership

• Lead daily revenue operations and clean-claim activities within the assigned scope.
• Establish work priorities, queue of ownership, service expectations, escalation standards, and quality requirements.
• Ensure claims are assigned, reviewed, documented, corrected, submitted, and escalated consistently.
• Monitor staffing capacity, workload distribution, productivity, quality, and turnaround time.
• Lead employee selection, onboarding, coaching, cross-training, competency development, and performance management.

Claim Creation, Validation, and Submission Readiness

• Oversee claim creation and validation after the appropriate operational handoff and delivery milestone.
• Confirm required billing data, payer information, codes, modifiers, units, dates, pricing, documentation references, and claim-format requirements are complete and accurate.
• Apply approved payer and billing rules to determine claim readiness.
• Prevent incomplete, unsupported, duplicate, or inaccurate claims from entering the submission workflow.
• Ensure claims are submitted or released within applicable filing requirements and internal turnaround standards.

Clean Claim and Billing Quality Management

• Establish clean-claim review standards and quality control processes.
• Monitor clean claim rate, first-pass acceptance rate, rejection rate, correction volume, and repeat billing defects.
• Conduct or oversee targeted quality reviews based on risk, trend, payer, employee, product, code, or workflow.
• Identify recurring billing defects and coordinate corrective actions with the appropriate business owner.
• Maintain quality evidence, defect categories, corrective action records, and follow-up validation.

Rejection, Exception, and Correction Management

• Oversee rejected, suspended, returned, documentation-pending, and correction-required claim queues.
• Define when an item can be corrected within Revenue Operations and when it must be returned to Order Management or another source of owner.
• Monitor failed or incomplete GenHealth-enabled and NikoHealth-supported transactions.
• Ensure exceptions include a clear reason, assigned owner, next action, due date, and escalation status.
• Analyze rejection and exception trends and escalate systemic risks.

Work-Queue and Timely Filing Governance

• Maintain disciplined queue of ownership, aging standards, follow-up expectations, and escalation thresholds.
• Monitor unbilled, held, rejected, returned, suspended, and unresolved claim activity.
• Protect timely filing through proactive aging review and escalation.
• Identify bottlenecks, stalled handoffs, and unresolved documentation dependencies.
• Provide leadership visibility into claim volume, queue aging, financial exposure, and operational barriers.

Cross-Functional Handoffs and Corrective Action

• Partner with Order Management when missing or inaccurate upstream information affects claim readiness.
• Provide structured feedback on authorization, documentation, payer, demographic, product, or order defects that create billing risk.
• Partner with Revenue Recovery on denial and nonpayment trends requiring upstream billing correction.
• Partner with Payment Integrity & Revenue Performance when financial findings indicate a claim-build, posting, adjustment, or workflow concern.
• Partner with Revenue Systems Strategy & Business Optimization on business requirements, workflow redesign, SOP standards, UAT, and corrective-action implementation.

Revenue Systems Support

• Provide business requirements and operational subject matter expertise for GenHealth and NikoHealth billing workflows.
• Participate in UAT, process validation, training, implementation of readiness, and stabilization activities.
• Monitor automation exceptions, manual rework, output accuracy, and workflow adoption within Revenue Operations.
• Escalate recurring workflow or configuration concerns to Revenue Systems Strategy & Business Optimization and the Operations Product Owner & Systems Administrator.
• Maintain clear separation between business workflow ownership and technical system administration.

Analytics and Reporting

• Develop or maintain operational dashboards, queue reports, quality summaries, and clean-claim performance reporting.
• Analyze claim volume, acceptance, rejection, correction, aging, productivity, and quality trends.
• Quantify financial exposure associated with billing defects, held claims, untimely action, and unresolved exceptions.
• Provide accurate, timely, and decision-ready reporting to department leadership.
• Use performance data to coach employees, prioritize improvement of work, and validate results.

Performance Expectations

• Improve clean claim rate and first-pass acceptance rate.
• Reduce preventable rejections, corrections, billing defects, and manual rework.
• Maintain timely claim release and filing compliance.
• Ensure revenue operations queues are assigned, current, documented, and escalated consistently.
• Improve claim readiness and reduce unresolved handoff defects.
• Provide timely and accurate operational reporting.
• Convert recurring billing findings into sustainable corrective actions.

Qualifications

Minimum Qualifications

• Bachelor's degree in healthcare administration, Business Administration, Finance, Operations Management, or a related field, or an equivalent combination of education and directly related experience.
• Seven or more years of progressive healthcare billing, claims, revenue operations, or revenue cycle experience.
• Three or more years of supervisory, team-lead, management, or formal cross-functional leadership experience.
• Demonstrated knowledge of claim creation, billing requirements, corrections, rejections, EDI or clearinghouse workflows, timely filing, and work-queue management.
• Experience managing productivity, quality, turnaround time, and operational performance.
• Experience analyzing billing defects and implementing corrective actions.
• Proficiency with Excel, healthcare billing systems, and operational reporting.
• Strong communication, prioritization, documentation, and cross-functional leadership skills.

Preferred Qualifications

• DME/HME billing or revenue operations leadership experience.
• Commercial, Medicare Advantage, Medicaid Managed Care, or multi-payer billing experience.
• Experience with NikoHealth or a comparable DME/HME or healthcare revenue-cycle platform.
• Experience supporting GenHealth or another automated claims, quality