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Research & Resolution Specialist

Research & Resolution Specialist

Job Locations 
US-VA-Glen Allen
Job ID 

Job Description


The position is responsible for all research and resolution of claims inquiries and Claims Reconsiderations escalated by provider for all lines of business.  


  • Research and resolve claims issues that have been escalated by providers through Claims Reconsiderations and Claims Inquiries that are brought forth by Claims Customer Service, Network Development, and Provider Resolution Managers
  • Research and resolution may include coding/billing issues, systemic claims issues, electronic submissions, and refunds received
  • Coordinate claims resolutions with all appropriate departments in order to resolve issues
  • Process, adjust, and key claims accurately and timely following established guidelines for accuracy, quality, and productivity
  • Identify track and trend claims payment errors in order to determine root causes and actions needed to correct problems. 
  • Identify trends from provider complaints regarding code edits and business decisions that impact claims payments
  • Other miscellaneous duties/activities as assigned
  • The ability to work overtime as needed



  • High School diploma required 


  • Strong communication skills (both verbal and written)
  • Exposure to health care call center environment
  • Ability to conduct research
  • Experience with IDX and QNXT Claim processing systems
  • Ability to work independently as well as in a team environment
  • Strong organizational skills
  • Strong Time Management skills
  • Knowledge of CPT-4, HCPCS coding and ICD10
  • Knowledge of CMS 1500 and UB04 claim forms
  • Ability to meet deadlines and work under pressure 


  • Minimum 3 years claim processing experience, preferably with Medicare/Medicaid 


  • Physical health sufficient to meet the ergonomic standards and demands of the position.


About Us

Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!

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