About the Role
Handles high-complexity claims, performs in-depth reviews, and ensures accurate benefit adjudication while adhering to policies and regulations.
Responsibilities
- Evaluate intricate healthcare claims for proper benefit application
- Resolve escalated claim disputes with precision and compliance
- Interpret plan documents and policy guidelines to determine coverage
- Collaborate with internal teams to clarify claim discrepancies
- Ensure claims are processed within regulatory and contractual standards
- Maintain accurate records of claim decisions and communications
- Support members by explaining claim outcomes and benefit details
- Identify trends in claim errors and recommend process improvements
- Participate in training and quality assurance initiatives
- Respond to inquiries from providers and members in a timely manner
- Apply medical terminology and coding standards to claim review
- Verify eligibility and coverage terms for accurate processing
- Escalate unresolved issues following defined protocols
- Follow data privacy and security requirements in handling claims
- Use multiple systems to retrieve and update claim information
- Meet performance metrics for accuracy and productivity
- Stay current with changes in healthcare policies and benefit plans
- Assist in audits and compliance reviews as needed
- Document root causes of claim rejections or denials
- Provide feedback to improve claims processing workflows
- Support team members with complex case resolution
- Maintain consistent communication with cross-functional partners
- Adhere to service level agreements for response times
- Apply critical thinking to interpret ambiguous policy language
- Ensure equitable treatment across all claim cases
Compensation
Competitive hourly wage with benefits
Work Arrangement
Remote
Team
Part of the claims operations team supporting healthcare benefit processing
Work Environment
- Fully remote position with structured virtual collaboration
- Standard business hours with some flexibility based on team needs
- Regular use of digital communication and case management tools
- Occasional virtual meetings with cross-functional teams
- Performance evaluated through quality, accuracy, and timeliness metrics
Growth Opportunities
- Pathways for advancement within claims and operations teams
- Access to professional development resources
- Opportunities to lead process improvement projects
- Mentorship and coaching from senior staff
- Training on emerging healthcare regulations and systems
Not available
