Claims Representative

This is a fully remote position, open to applicants in North Carolina, +2 more states.

📋 Description

• Assess and promptly adjudicate claims.

• Administer claims in line with contractual benefits and healthcare policies.

• Oversee daily work queues and ensure claims processing quality.

• Monitor claim turnaround times to meet compliance guidelines and performance standards.

• Process, adjust, or update routine claims payments and rectify payment errors.

• Address inquiries from service teams, subscribers, providers, physicians, and other insurance carriers.

• Determine methods for resolving suspended claims by reviewing benefit eligibility, claims history, and additional information.

• Identify system issues, document problems, propose solutions, refer matters to technical staff, and follow up on resolutions.

• Support management by identifying and analyzing opportunities for process, policy, and service improvements.

• Collaborate with other insurance carriers and Medicare to ascertain payment liability.

• Review claims for potential fraud and abuse, referring them to the Special Investigations Unit.

⛳️ Requirements

• High school diploma or GED required.

• 0-2 years of experience in a related field.

• Data entry experience is advantageous.

• Understanding of contractual benefits and healthcare policies.

• Experience in claims processing, adjudication, analysis, management, review, and resolution.

• Strong customer service skills.

• Knowledge of insurance and medical claims processing.

• Familiarity with Medicare.

• Ability to identify and document system issues.

• Capability to analyze opportunities for process improvement.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Health and wellness programs.

• Parental leave and support.

• Adoption and surrogacy assistance.

• Career development programs.

• Tuition reimbursement for ongoing education.

• 401k match along with an annual company contribution.

• Annual Incentive Bonus.

• Paid Time Off (PTO).

• Flexible work arrangements.

• Remote work with occasional in-office visits each year for Remote Flex roles.