Claims Representative

Overview

• The Claims Representative role involves processing and adjudicating health insurance claims accurately and efficiently.
• Ensure compliance with company policies, contractual agreements, and regulatory requirements.
• Provide timely claim resolution by verifying eligibility, benefits, and documentation.
• Apply appropriate coding and payment guidelines to claims processing.
• Identify discrepancies and potential issues for follow-up actions.
• Support claim inquiries and provide clarification on claim status.
• Collaborate with internal and external stakeholders to ensure operational success.
• Contribute to team-wide goals and daily operational objectives.

Key Responsibilities & Duties

• Develop a comprehensive understanding of administrative operations systems and workflows.
• Analyze and improve review processes for consistency and quality.
• Monitor and track work-in-progress issues to ensure timely resolution.
• Manage escalations and resolutions with external vendors for prompt turnaround.
• Ensure compliance with applicable laws and regulations.
• Handle personal health information professionally and securely.
• Support team goals and contribute to operational success.
• Perform other duties as assigned to support claims production.

Job Requirements

• High School Diploma or GED required; Bachelor’s degree preferred.
• Minimum 1 year of experience in claims processing, data analytics, or related fields.
• Proficiency in Excel or Google Sheets for quantitative analysis.
• Strong verbal and written communication skills.
• Ability to navigate multiple systems and solve problems within guidelines.
• Experience with claims resolution systems and insurance operations.
• Demonstrated ability to balance competing priorities effectively.
• Knowledge of health insurance protocols and payment schemes preferred.