Claims Resolution Specialist

Claims Resolution Specialist Overview

• The Claims Resolution Specialist role offers an opportunity to work remotely, handling medical claims and correspondence with clients regarding out-of-pocket expenses.
• This position is a contract role lasting 60-90 days, with potential for extension based on performance and business needs.
• Work hours are flexible within the candidate's timezone, ensuring a convenient and productive work environment.
• Candidates will receive comprehensive training on systems and processes to ensure success in the role.
• The role requires handling email correspondence with clients, focusing on claims resolution and dispute management.
• Ideal candidates will have experience in health plan operations and demonstrate multitasking and quick learning abilities.
• This position offers the chance to contribute to a dynamic team within a healthcare-focused organization.
• Equipment for remote work will be provided, ensuring seamless integration into the role.

Claims Resolution Specialist Key Responsibilities & Duties

• Review, analyze, and adjudicate medical claims following plan benefits, policies, and regulatory requirements.
• Investigate and resolve balance billing disputes, ensuring compliance with federal and state regulations.
• Process reimbursement requests, validate documentation, and ensure adherence to coverage standards.
• Communicate with members and providers regarding claims determinations and payment responsibilities.
• Collaborate with internal teams to resolve complex cases and improve processes.
• Document claim decisions and resolution steps accurately in claims and CRM systems.
• Participate in training and meetings to maintain current knowledge of policies and regulations.
• Ensure compliance with HIPAA standards and maintain a secure remote work environment.

Claims Resolution Specialist Job Requirements

• High School Diploma or GED required; college education in a relevant field preferred.
• Minimum of 1 year experience in healthcare claims processing, billing, or resolution.
• Proficiency in medical coding (ICD-10, CPT, HCPCS) and claims adjudication rules preferred.
• Knowledge of health plan benefit structures such as PPO and EPO.
• Strong analytical and problem-solving skills with attention to detail.
• Proficiency in Google Workspace or Microsoft Office, especially Excel or Sheets.
• Familiarity with claims processing platforms and CRM systems is a plus.
• Ability to manage multiple priorities in a fast-paced environment.