Healthcare Support Representative

This is a fully remote position, open to applicants in India, +1 more country.

📋 Description

• Manage incoming and outgoing inquiries from members and providers through phone, email, and chat while demonstrating professionalism and empathy.

• Proactively reach out to members to offer information and assistance related to their benefits.

• Deliver precise information concerning benefits, eligibility, and coverage; claims statuses and adjudication specifics; prior authorization requirements and submissions; billing and reimbursement policies; as well as support for provider portal navigation.

• Address inquiries, complaints, grievances, and escalations promptly, ensuring thorough documentation and appropriate routing when necessary.

• Conduct follow-up outreach to guarantee resolution, member satisfaction, and continuity of care or claim outcomes.

• Establish trust with members and providers through early, consistent, and tailored engagement.

• Process, investigate, and adjudicate institutional and professional medical claims (including behavioral health), ensuring accuracy, timeliness, and compliance.

• Verify eligibility, coverage, and medical necessity in accordance with policy guidelines utilizing established systems and workflows.

• Examine and resolve claim denials, appeals, discrepancies, overpayments, and billing errors, as well as payment issues.

• Conduct overpayment audits, coordinate recovery efforts, and correct claim financial histories as required.

• Assist with high-cost claim and claimant processes as needed.

• Perform provider outreach as necessary to facilitate claims resolution, documentation requirements, and payment accuracy.

• Gather W-9 forms and maintain accurate provider information within XO systems to support claims processing, reporting, directory publication, and data transfers.

• Collaborate with Business Operations, Network Performance, Product, and Experience teams to address complex cases and enhance service delivery.

• Coordinate with third-party claims vendors to ensure accuracy, compliance, and exceptional service.

• Identify recurring issues, system deficiencies, or process inefficiencies and provide constructive feedback to leadership.

• Conduct quality assurance reviews to confirm claims financial and procedural accuracy.

• Document procedures, workflows, and operational guidance as necessary.

• Achieve performance objectives in areas such as efficiency and productivity, quality and accuracy, customer satisfaction, compliance, follow-up completion, and attendance.

• Uphold confidentiality and adhere to HIPAA, ERISA, and XO Health policies.

⛳️ Requirements

• 3–5 years of experience in a healthcare payer, TPA, or health insurance setting, with a combination of contact center/member-provider support and/or medical claims processing/adjudication/claims operations.

• In-depth understanding of health insurance principles, benefits and eligibility, medical terminology, and claims lifecycle management.

• Excellent verbal and written communication skills in English, with a compassionate, solution-focused approach.

• High attention to detail, sound judgment, and strong analytical problem-solving capabilities.

• Ability to multitask effectively in a fast-paced, digital-first environment while ensuring accuracy and professionalism.

• Proficiency in Microsoft Office Suite and experience with customer service and/or claims processing systems.

🏝️ Benefits

• Competitive salary and comprehensive health benefits.

• Opportunities for professional development and career advancement.

• Supportive work environment focused on team collaboration and success.