Claims Research Resolution Rep

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

Job summary

Jobgether SRL is partnering to fill a Claims Research Resolution Rep role in the United States. You will resolve complex healthcare claims, review supporting docs, and apply policies to determine resolutions. The position emphasizes accuracy, privacy, and timely outcomes while collaborating with providers, members, and internal teams.

The role offers a remote work setup within the U.S. and includes a structured eight-week training program, with expectations to remain in role for 18 months and

Qualifications

• At least one year of healthcare customer service experience.
• At least one year of call center experience.
• Intermediate proficiency in Microsoft Excel.
• Intermediate proficiency in Microsoft Word.
• Working knowledge of healthcare terminology and medical claims processes.
• Familiarity with Medicare or Medicaid claims.

Responsibilities

• Investigate, research, and resolve complex medical claims issues with providers, members, and third-party services to achieve accurate outcomes.
• Review claims discrepancies, validate documentation, and apply policies and regulatory requirements.
• Collaborate with claims specialists and internal stakeholders to investigate pending claims and address issues.
• Respond to inquiries through multiple channels, adapting to workload and priorities.
• Maintain records of investigations and decisions with strict data privacy.

Skills

Healthcare terminology

Customer service

Call center

Excel

Word

Analytical skills

Communication

Privacy/compliance

Job description

This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Claims Research Resolution Rep based in the United States.

As a Claims Research Resolution Representative, you will play a vital role in resolving complex healthcare claims and ensuring accurate, timely outcomes for members and healthcare providers. You will investigate claim discrepancies, review supporting documentation, and apply your knowledge of healthcare policies and procedures to address challenging cases. Working with providers, members, collection agencies, and internal teams, you will help streamline claims resolution and improve the overall service experience. This remote opportunity is ideal for a detail-oriented professional who thrives in a structured, fast-paced environment and can manage competing priorities independently. You will receive comprehensive virtual training to develop your expertise in claims operations, systems, and regulatory requirements. Your work will contribute directly to efficient healthcare administration and reliable member support.

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.