Account Resolution Specialist – Insurance HMOs

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct research and resolve pending insurance claims, including those that cannot be released, have been denied, or were incorrectly processed by commercial insurance providers.

• Examine claims that are on hold, pinpointing root causes, rectifying errors, and carrying out necessary follow-up actions to enable claims for processing.

• Review insurance denials to identify the reasons behind them, evaluate their validity, and complete appropriate resolution actions such as appeals, corrections, or resubmission.

• Directly communicate with insurance carriers through outbound calls to gather claim statuses, clarify any discrepancies, and obtain detailed explanations for claims that are pending or denied.

• Prepare and submit any additional documentation requested by insurance carriers to aid in claim adjudication and ensure proper processing.

• Draft and file appeals when required, ensuring they are backed by the necessary documentation, regulatory guidelines, and specific payer requirements.

• Process and handle incoming correspondence, including mail, emails, Explanation of Benefits (EOBs), requests for information, and any applicable refunds.

• Maintain precise, detailed notes in billing systems regarding all follow-up activities, findings, and subsequent steps.

• Identify trends or recurring issues, escalating concerns to supervisors or relevant internal teams to facilitate process improvements.

• Meet daily productivity and accuracy standards, contributing to a high-performance team atmosphere.

• Additional responsibilities as assigned.

⛳️ Requirements

• Education: High School Diploma or equivalent is required.

• Proficient computer skills, including a working knowledge of MS Outlook, Word, and Excel.

• Ability to type at least 40 words per minute with accuracy.

• Demonstrated capability to manage high-volume workloads, effectively prioritize tasks, and meet stringent deadlines.

• Experience in a structured environment utilizing call monitoring, performance metrics, or productivity scoring is advantageous.

• Strong verbal communication skills, maintaining composure, professionalism, and effectiveness during phone interactions with insurance carriers.

• Excellent written communication skills for producing clear and precise documentation and correspondence.

• Exceptional attention to detail and accuracy when reviewing claims, identifying discrepancies, and documenting findings.

• Highly organized, self-motivated, and capable of managing work independently in a remote setting.

• Reliable, punctual, and accountable, with a readiness to ask questions and seek clarification when necessary.

• Ability to independently oversee all aspects of the job role, including achieving required goals and adhering to business practices in a remote environment.

🏝️ Benefits

• Competitive salary, based on experience.

• Comprehensive benefits package, including a 401(k) plan.