Claims Research & Resolution Representative

Accountabilities:

• Handle inbound calls from members, providers, insurance companies, and other stakeholders, addressing questions and resolving claims-related issues.
• Research and resolve moderately complex claims inquiries, including financial recovery, overpayment, and other claims-related matters.
• Conduct outbound calls when necessary to follow up on cases, gather additional information, or facilitate resolution.
• Document inquiries, complaints, transactions, interactions, research findings, and actions taken accurately within internal systems.
• Investigate pending claims and inquiries using available internal resources, systems, policies, and reference tools.
• Escalate unresolved or pending issues appropriately while maintaining ownership of the customer experience.
• Interpret departmental policies, procedures, and established methods to determine appropriate courses of action.
• Exercise independent judgment within defined guidelines when prioritizing workload, managing cases, and determining appropriate resolutions.
• Manage multiple and competing priorities while maintaining productivity, accuracy, and service-quality standards.
• Cross-train across departmental functions and develop proficiency in multiple claims-related processes.
• Maintain strict confidentiality when handling protected health information and other sensitive customer or claims data while working remotely.
• Participate fully in required virtual training and the initial appraisal period to develop proficiency across systems, policies, and processes.

Requirements:

• At least 1 year of call-center or telephone-based customer service experience gained within the past 5 years.
• Previous healthcare-related work experience or education.
• Basic proficiency with Microsoft Office applications, including Word, Excel, Outlook, and Teams.
• Strong technical skills and the ability to navigate and work across multiple software systems simultaneously.
• Ability to independently research and resolve issues using internal system resources and available knowledge tools.
• Strong time-management and prioritization skills, with demonstrated ability to manage multiple or competing priorities.
• Self-reliant and adaptable approach, with the ability to work effectively with minimal supervision.
• Strong communication and customer service skills, particularly in a telephone-based environment.
• Ability to maintain confidentiality and appropriately safeguard protected health information (PHI/HIPAA) while working from home.
• Willingness to complete up to 8 weeks of virtual training, Monday through Friday from 8:00 AM to 4:30 PM Eastern Time, with full attendance expected during training.
• Ability to work an assigned 8-hour shift between 8:00 AM and 6:00 PM Eastern Time following training.
• Willingness to remain in the position for at least 12 months before applying for other internal opportunities.
• A bachelor's degree is preferred.
• Prior claims processing, overpayment, or financial recovery experience is advantageous.
• Experience with Mentor, PrePay, Post Pay, CAS, CIS, CISPRO, or CRM systems is a plus.
• Reliable home internet connection with at least 25 Mbps download and 10 Mbps upload speeds.
• Access to a dedicated, interruption-free workspace suitable for protecting confidential health and customer information.
• Ability to travel occasionally to an office location for training or meetings if required.

Benefits:

• Annual salary: $40,000–$52,300, with individual compensation varying based on location, skills, experience, education, certifications, and other job-related factors.
• Full-time schedule of 40 hours per week.
• Fully remote work opportunity within the United States.
• Comprehensive medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, company holidays, and personal holidays.
• Paid parental and caregiver leave.
• Short-term and long-term disability coverage.
• Life insurance.
• Professional development and continued education opportunities.
• Structured virtual onboarding and training of up to 8 weeks.
• Cross-training across departmental functions to broaden claims and operational expertise.
• Potential overtime opportunities based on business needs.
• Opportunity to develop experience in healthcare claims, customer resolution, financial recovery, and claims operations.
• Remote-work flexibility supported by established technology and work-from-home requirements.