Claims Research Resolution Rep

Jobgether SRL; United States; Remote; USD 43,000 - 56,000; Full time

Benefits offered by this job

Remote work

Healthcare coverage

401(k) retirement plan

Paid time off

Parental leave

Disability & life insurance

Structured onboarding

Professional development

Team collaboration

Well-being resources

Job summary

Jobgether SRL is seeking a Healthcare Claims Support Specialist in the United States to investigate and resolve complex medical claims by working with providers, members, and third-party services. This role requires strong analytical skills, healthcare knowledge, and customer-focused communication.

You will review discrepancies, validate documentation, and apply policies to reach timely resolutions. A remote work setup is available with training and career development opportunities.

Qualifications

• At least one year of healthcare customer service experience.
• At least one year of call center experience.
• Intermediate proficiency in Microsoft Excel to organize, review, and analyze data.
• Intermediate proficiency in Microsoft Word for documentation and admin tasks.
• Working knowledge of healthcare terminology and medical claims processes.
• Familiarity with Medicare or Medicaid claims and related procedures.
• Strong analytical and problem-solving skills for discrepancies.
• Excellent verbal and written communication with a customer focus.
• Strong organizational skills and ability to manage competing priorities.
• Ability to work independently and adapt to changing workloads.
• Quiet, secure home workspace with reliable internet (25 Mbps down, 10 Mbps up).
• Ability to protect confidential member information and privacy requirements.

Responsibilities

• Investigate, research, and resolve complex medical claims issues with providers, members, and third-party services.
• Review claims discrepancies, validate documentation, and apply policies to determine resolutions.
• Collaborate with claims specialists, call center reps, provider associates, and other stakeholders.
• Respond to claims inquiries through various channels, adjusting to workload changes.
• Apply judgment to determine effective resolution strategies and handle admin tasks independently.
• Maintain accurate records of investigations and decisions while ensuring data security.
• Manage multiple assignments and shift between projects as workload changes.
• Participate in training, team meetings, and ongoing learning to stay proficient.

Skills

Healthcare terminology

Analytical skills

Customer service

Communication skills

Time management

Independence

Privacy & data security

Tools

Microsoft Excel

Microsoft Word

Microsoft Access

Job description

Accountabilities

• Investigate, research, and resolve complex medical claims issues by working with healthcare providers, members, and third-party collection services to achieve accurate and timely outcomes.
• Review claims discrepancies, validate supporting documentation, and apply established policies, procedures, and regulatory requirements to determine appropriate resolutions.
• Collaborate with claims specialists, call center representatives, provider associates, and other internal stakeholders to investigate pending claims and address outstanding issues.
• Respond to claims inquiries through various communication channels, adapting to changing workloads and business priorities.
• Apply sound judgment, discretion, and in-depth knowledge of claims processes to determine effective resolution strategies and manage administrative tasks independently.
• Maintain accurate records of investigations, decisions, and resolution activities while ensuring the confidentiality and security of sensitive healthcare information.
• Manage multiple assignments efficiently, shifting between projects and support requests as workload demands change.
• Participate in required training, team meetings, and ongoing learning activities to maintain proficiency in claims systems, policies, and operational procedures.

Requirements

• At least one year of healthcare customer service experience.
• At least one year of call center experience.
• Intermediate proficiency in Microsoft Excel, including the ability to organize, review, and analyze data.
• Intermediate proficiency in Microsoft Word for documentation and administrative tasks.
• Working knowledge of healthcare terminology and medical claims processes.
• Familiarity with Medicare or Medicaid claims and related healthcare procedures.
• Strong analytical and problem-solving skills, with the ability to investigate discrepancies, evaluate documentation, and resolve complex inquiries.
• Excellent verbal and written communication skills, with a customer-focused approach when interacting with members, providers, and internal teams.
• Strong organizational skills, attention to detail, and the ability to manage competing priorities in a fast-paced environment.
• Ability to work independently, exercise sound judgment, and adapt to changing workloads and business requirements.
• A suitable home workspace that is quiet, secure, and free from ongoing interruptions, with reliable internet access meeting the minimum requirements of 25 Mbps download and 10 Mbps upload.
• Ability to protect confidential member information and comply with applicable privacy and healthcare data security requirements.

Preferred qualifications

• Previous experience in a healthcare call center or medical claims processing environment.
• Experience managing member reimbursement claims.
• Familiarity with Microsoft Access and other claims administration tools.
• Knowledge of the Medicare industry and healthcare benefits.

Work schedule and training requirements

• Completion of an eight-week virtual training program scheduled Monday through Friday, from 8:00 a.m. to 4:30 p.m. Eastern Time.
• Full attendance and punctuality throughout training, with the camera on and appropriate attire required during training, nesting, and designated meetings.
• No time off permitted during training or the first 120 days of employment, except for company-observed holidays.
• Availability to work Monday through Friday, with shifts scheduled between 6:00 a.m. and 5:30 p.m. Eastern Time after training.
• Commitment to remain in the position for at least 18 months before applying for opportunities outside the team.
• Willingness to travel occasionally to designated offices for meetings or training, if required.

Benefits

• Competitive annual salary: $43,000–$56,200, depending on qualifications, relevant experience, skills, and geographic location.
• Remote work opportunity: Work from home within an eligible U.S. location, subject to operational and technical requirements.
• Healthcare coverage: Medical, dental, and vision insurance.
• Retirement savings: Access to a 401(k) retirement savings plan.
• Paid time off: Paid leave, company holidays, and personal holidays.
• Family support: Paid parental and caregiver leave.
• Insurance protection: Short-term and long-term disability coverage and life insurance.
• Structured onboarding: Eight weeks of virtual training to develop knowledge of claims procedures, systems, and healthcare policies.
• Professional development: Opportunities to strengthen healthcare claims expertise, customer service capabilities, and problem-solving skills.
• Collaborative environment: Work alongside specialized claims, provider, and customer service teams.
• Well-being resources: Benefits designed to support employee health, financial security, and work-life needs.