This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Claims Research & Resolution Representative based in United States.
This role sits at the center of claims operations, where accuracy, investigation, and member support directly shape outcomes for customers and providers. You will handle complex claim inquiries involving research, validation, and resolution across a variety of healthcare scenarios. The position requires strong analytical thinking, attention to detail, and the ability to interpret policies and procedures with confidence. You will collaborate with insurance partners, providers, and members to resolve disputes and ensure timely settlements. Working in a structured yet fast-paced environment, you will exercise independent judgment while maintaining compliance with regulatory and confidentiality standards. This is a highly impactful role where your decisions help ensure fair, accurate, and efficient claims processing.
Accountabilities:
- Manage end-to-end claims research, investigation, and resolution activities
- Review claim details, identify discrepancies, and determine appropriate outcomes
- Communicate with members, providers, and insurance carriers to resolve claim issues
- Apply policies, procedures, and regulatory guidelines to ensure accurate adjudication
- Approve or recommend claim settlements based on findings and authority level
- Document case progress, maintain records, and ensure timely claim closure
- Ensure confidentiality and compliance with healthcare and data protection standards
- Prioritize multiple claims while maintaining accuracy and meeting deadlines
Requirements:
- 1+ year of experience in call center, customer service, or related support roles
- Experience in healthcare claims processing preferred
- Strong understanding of medical terminology and insurance processes (preferred)
- Bachelor’s degree is a plus
- Ability to analyze data and apply policies to real-world claim scenarios
- Strong communication and interpersonal skills for stakeholder interaction
- High attention to detail and ability to work with sensitive information
- Ability to work independently with limited supervision
- Intermediate mathematical and analytical skills
Benefits:
- Competitive annual salary based on experience and location
- Medical, dental, and vision insurance coverage
- 401(k) retirement savings plan
- Paid time off, including holidays, vacation, and sick leave
- Paid parental and caregiver leave
- Short-term and long-term disability insurance
- Life insurance coverage
- Structured remote work arrangement with internet requirements support
- Opportunities for growth within a healthcare-focused organization
How Jobgether works:
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.
#LI-CL1
