Claims Associate

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

📋 Description

• Manage assigned claims cases promptly and efficiently.

• Investigate and resolve issues related to benefit claims, billing discrepancies, coding mistakes, and insurance claims processing.

• Inform members regarding their benefit plan coverage and relevant policies.

• Collaborate with plan documents, carriers, healthcare providers, members, and supervisors to find resolutions.

• Research conflicting information regarding plans and escalate for clarification when necessary.

• Investigate billing inaccuracies and assist with the resubmission of claims.

• Aid members in establishing payment arrangements and communicate with healthcare providers about payment options.

• Utilize plan documents, benefit summaries, enrollment materials, and coverage information to address billing issues.

• Stay updated on FSA, HRA, HSA, and SPD information.

• Process claims in accordance with policies, procedures, quality standards, and federal laws and regulations.

• Assist with routine program quality concerns and claims research.

• Reach out to healthcare providers to obtain necessary documentation such as bills and medical records.

• Oversee claims research until resolution is achieved.

• Document claims issues and maintain department files and databases.

• Prioritize tasks to ensure prompt and quality service delivery.

• Monitor trends in issues and escalate them to supervisors as required.

• Foster professional relationships with both internal and external customers and team members.

• Collaborate with team members to achieve goals and complete tasks.

• Deliver outstanding customer service and escalate situations beyond the employee's control.

⛳️ Requirements

• High School Diploma or GED is mandatory.

• An Associate degree in business administration, liberal arts, public health, healthcare management, or a related field is preferred.

• At least one year of experience in customer service, healthcare, or claims is required.

• Fundamental knowledge of MS Word and Excel is essential.

• Must achieve acceptable scores on job-related testing.

• Ability to pass a standardized interview is necessary.

• Bilingual capabilities in English, Spanish, etc., may be required depending on the program.

• Familiarity with the Affordable Care Act (ACA), COBRA, Medicare, various benefit plan options, group benefits, medical benefits, pharmacy benefits, vision benefits, FSA/HSA, HRA, disability, long-term care, individual health plans, and temporary plans is preferred.

• Strong focus and attention to detail are critical.

• Possess critical thinking and problem-solving abilities.

• Strong verbal and written communication skills are essential.

• Ability to work effectively in a distraction-free home office environment.

• Proficient in using computers, telephones, printers, and general computer software consistently throughout the workday.

• Capability to perform extended periods of sitting, typing, mouse navigation, screen reading, finger movements, grasping, pulling hand-over-hand, and repetitive motions.

🏝️ Benefits

• Comprehensive training provided to ensure effective job performance.

• Opportunities for career advancement.

• Supportive and approachable supervisors and staff.

• Fully remote working arrangement.

• Home office environment.