Claims Research Resolution Rep

Accountabilities

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