Claims & Benefits Resolution Specialist

Our client is seeking a Claims & Benefits Resolution Specialist for a contract opportunity. This role performs comprehensive audits and resolution activities across the claims lifecycle, ensuring accurate billing, timely reimbursement, and compliance with payer requirements. The specialist will handle complex claim discrepancies, conduct follow-up with payers, and coordinate with clinical and non-clinical teams to finalize claim determinations. The ideal candidate has strong revenue cycle experience, particularly in claims, eligibility, benefits, and authorizations, and can quickly identify root-cause errors in a high-volume environment. This is an operational “fix-it” position — the manager needs someone who doesn’t just process claims but can find what’s broken and correct it without hand-holding. Key Responsibilities : Claims Audit & Correction Perform comprehensive audits on assigned accounts to identify billing, payment, and adjustment errors. Correct claim discrepancies within established turnaround times. Ensure claim data accuracy, compliant coding, and alignment with the member’s plan benefit. Timely & Accurate Claims Processing Process claims quickly and accurately according to organizational benchmarks. Apply reimbursement rules based on the member’s benefits and plan specifications. Validate supporting documentation needed for accurate processing (eligibility, benefits, authorizations, etc.). Complex Follow-Up & Dispute Resolution Conduct follow-up on delayed, denied, or pended claims; escalate unresolved items as needed. Investigate processing delays, missing information, or system errors and implement corrective action. Refer cases to clinical management teams when medical review is required to ensure appropriate reimbursement. Eligibility, Benefits & Authorization Coordination Verify and document member eligibility, benefits coverage, and authorization requirements. Identify discrepancies in coverage or authorizations that impact payment determinations. Communicate directly with payers or internal departments to resolve missing or inconsistent benefit information. Cross-Functional Collaboration Work closely with leadership, clinical review staff, and the CBO team to ensure timely resolution of claim issues. Participate in problem-solving discussions related to claim trends or systemic issues. Support training and onboarding efforts as needed during onsite sessions. Required Skills & Experience : Minimum 2+ years of experience in healthcare revenue cycle, claims processing, eligibility / benefits, or authorizations. Strong understanding of payer rules, reimbursement methodologies, and claims adjudication. Familiarity with Epic, payer portals, and other claims / RCM systems. High accuracy in auditing and error resolution work. Experience resolving complex claim issues across multiple systems. Ability to work independently, troubleshoot problems, and drive claims to completion Strong communication skills for interacting with payers, internal teams, and leadership. Comfortable with onsite onboarding and required monthly onsite days. Experience working in a Central Business Office or Shared Services model. Prior experience supporting Utah-based payer populations or multi-state payer networks. Kavaliro provides Equal Employment Opportunities to all employees and applicants. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Kavaliro is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Kavaliro will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and / or to receive all other benefits and privileges of employment, please respond to this posting to connect with a company representative.