Claims Research Resolution Rep

<h3>Accountabilities</h3><li>Investigate, research, and resolve complex medical claims issues by working with healthcare providers, members, and third-party collection services to achieve accurate and timely outcomes.</li><li>Review claims discrepancies, validate supporting documentation, and apply established policies, procedures, and regulatory requirements to determine appropriate resolutions.</li><li>Collaborate with claims specialists, call center representatives, provider associates, and other internal stakeholders to investigate pending claims and address outstanding issues.</li><li>Respond to claims inquiries through various communication channels, adapting to changing workloads and business priorities.</li><li>Apply sound judgment, discretion, and in-depth knowledge of claims processes to determine effective resolution strategies and manage administrative tasks independently.</li><li>Maintain accurate records of investigations, decisions, and resolution activities while ensuring the confidentiality and security of sensitive healthcare information.</li><li>Manage multiple assignments efficiently, shifting between projects and support requests as workload demands change.</li><li>Participate in required training, team meetings, and ongoing learning activities to maintain proficiency in claims systems, policies, and operational procedures.</li><h2>Requirements</h2><li>At least one year of healthcare customer service experience.</li><li>At least one year of call center experience.</li><li>Intermediate proficiency in Microsoft Excel, including the ability to organize, review, and analyze data.</li><li>Intermediate proficiency in Microsoft Word for documentation and administrative tasks.</li><li>Working knowledge of healthcare terminology and medical claims processes.</li><li>Familiarity with Medicare or Medicaid claims and related healthcare procedures.</li><li>Strong analytical and problem-solving skills, with the ability to investigate discrepancies, evaluate documentation, and resolve complex inquiries.</li><li>Excellent verbal and written communication skills, with a customer-focused approach when interacting with members, providers, and internal teams.</li><li>Strong organizational skills, attention to detail, and the ability to manage competing priorities in a fast-paced environment.</li><li>Ability to work independently, exercise sound judgment, and adapt to changing workloads and business requirements.</li><li>A suitable home workspace that is quiet, secure, and free from ongoing interruptions, with reliable internet access meeting the minimum requirements of 25 Mbps download and 10 Mbps upload.</li><li>Ability to protect confidential member information and comply with applicable privacy and healthcare data security requirements.</li><h2>Preferred qualifications:</h2><li>Previous experience in a healthcare call center or medical claims processing environment.</li><li>Experience managing member reimbursement claims.</li><li>Familiarity with Microsoft Access and other claims administration tools.</li><li>Knowledge of the Medicare industry and healthcare benefits.</li><h2>Work schedule and training requirements:</h2><li>Completion of an eight-week virtual training program scheduled Monday through Friday, from 8:00 a.m. to 4:30 p.m. Eastern Time.</li><li>Full attendance and punctuality throughout training, with the camera on and appropriate attire required during training, nesting, and designated meetings.</li><li>No time off permitted during training or the first 120 days of employment, except for company-observed holidays.</li><li>Availability to work Monday through Friday, with shifts scheduled between 6:00 a.m. and 5:30 p.m. Eastern Time after training.</li><li>Commitment to remain in the position for at least 18 months before applying for opportunities outside the team.</li><li>Willingness to travel occasionally to designated offices for meetings or training, if required.</li><h2>Benefits</h2><li>
<strong>Competitive annual salary:</strong>$43,000–$56,200, depending on qualifications, relevant experience, skills, and geographic location.</li><li>
<strong>Remote work opportunity:</strong>Work from home within an eligible U.S. location, subject to operational and technical requirements.</li><li>
<strong>Healthcare coverage:</strong>Medical, dental, and vision insurance.</li><li>
<strong>Retirement savings:</strong>Access to a 401(k) retirement savings plan.</li><li>
<strong>Paid time off:</strong>Paid leave, company holidays, and personal holidays.</li><li>
<strong>Family support:</strong>Paid parental and caregiver leave.</li><li>
<strong>Insurance protection:</strong>Short-term and long-term disability coverage and life insurance.</li><li>
<strong>Structured onboarding:</strong>Eight weeks of virtual training to develop knowledge of claims procedures, systems, and healthcare policies.</li><li>
<strong>Professional development:</strong>Opportunities to strengthen healthcare claims expertise, customer service capabilities, and problem-solving skills.</li><li>
<strong>Collaborative environment:</strong>Work alongside specialized claims, provider, and customer service teams.</li><li>
<strong>Well-being resources:</strong>Benefits designed to support employee health, financial security, and work-life needs.</li>