SCIPPA Specialist

Overview

• The SCCIPA Specialist is responsible for completing routine SCCIPA claim adjudication work according to established workflows and payer requirements. This role reviews assigned claims, verifies claim and authorization information, enters adjudication outcomes accurately, documents claim activity, and identifies items requiring follow-up or escalation.
• The SCCIPA Specialist is expected to maintain accurate claim status updates, complete assigned adjudication work timely, and escalate claims that cannot be resolved through standard processes.

Responsibilities

Claim Adjudication

• Review assigned SCCIPA claims and complete adjudication activity according to established procedures.
• Verify claim details, authorization information, payer responses, and supporting documentation before completing adjudication.
• Enter adjudication outcomes accurately in the appropriate system or tracking tool.
• Identify claims that are pending, denied, underpaid, missing information, or otherwise unable to be adjudicated.
• Document adjudication notes, status updates, pending reasons, and next steps clearly and consistently.
• Follow established SCCIPA workflows for claim adjudication, follow-up, and escalation.

Authorization & Claim Validation

• Compare claim information against available authorization records to confirm accuracy before adjudication.
• Identify missing, incomplete, or mismatched authorization information.
• Document authorization discrepancies that impact claim adjudication.
• Follow standard steps to resolve routine authorization-related issues.
• Escalate authorization concerns that cannot be resolved through the standard workflow.

Denial & Pending Claim Follow-Up

• Review assigned denied or pending SCCIPA claims and update claim status information accurately.
• Identify basic denial or pending reasons based on payer response, authorization status, and claim documentation.
• Gather and document claim details needed for additional review.
• Track follow-up activity, including pending responses, reversal requests, corrected information, or unresolved items.
• Escalate complex denials, repeated issues, or claims requiring further review to the SCCIPA Analyst or leadership.

Documentation & Accuracy

• Maintain complete and accurate notes for all assigned claim adjudication activity.
• Ensure systems and trackers are updated timely and consistently.
• Follow established naming, status, and documentation standards.
• Review work for accuracy before marking claims complete.
• Communicate unclear items or process questions to the SCCIPA Analyst or leadership.

Productivity & Follow-Up

• Complete assigned SCCIPA adjudication work queues within expected timeframes.
• Prioritize work based on aging, pending status, payer response, and assigned deadlines.
• Follow up on outstanding adjudication items until resolved or escalated.
• Assist with assigned recheck, audit, or cleanup work related to SCCIPA claim adjudication.
• Maintain consistent productivity while ensuring accuracy and documentation quality.

Qualifications

• Experience in healthcare revenue cycle, medical claims, payment posting, adjudication, billing, collections, authorizations, or denial follow-up preferred.