Claims Specialist

Pride Health; New York (NY); On-site; USD 34,000 - 41,000; Full time

Benefits offered by this job

Health coverage

Dental & vision

401(k)

Life & disability insurance

Employee discounts

Job summary

Pride Global is seeking a dedicated Customer Service Representative to support members, providers, and prospective members in healthcare claims in New York. You will respond to inquiries, resolve claim-related issues, and document interactions in our tracking system.

The ideal candidate has strong communication skills, at least 1 year in healthcare or insurance customer service, and the ability to work in a fast-paced environment.

Qualifications

• High School Diploma or GED required.
• Minimum of 1 year of experience in a call center, customer service, or healthcare-related environment.
• Experience in health insurance or healthcare settings preferred.
• Strong written and verbal communication skills.
• Excellent customer service and problem-solving abilities.
• Proficiency with Microsoft Office applications.
• Experience with claims processing systems is a plus.

Responsibilities

• Respond to member and provider inquiries via phone and written correspondence.
• Document all customer interactions accurately in the tracking system.
• Investigate and resolve claim-related inquiries and billing issues.
• Process complaints and ensure timely follow-up and resolution.
• Assist members with PCP selection and demographic updates.
• Provide benefit and service information to members, providers, and prospective members.
• Coordinate with Claims, Provider Relations, Medical Management, and Member Services to resolve complex issues.
• Perform claim adjustments for overpayments and underpayments.
• Respond to written provider inquiries while maintaining accurate records.
• Handle provider roster updates, disenrollment requests, and utilization management inquiries.
• Conduct member orientations and outreach activities.
• Participate in special projects and claim status investigations.
• Maintain professionalism while handling escalated or challenging customer interactions.

Skills

Communication skills

Customer service

Problem-solving

MS Office

Documentation

Education

High School Diploma or GED

Tools

MS Office Suite

Claims processing systems

Job description

Job Title: Customer Service Representative – Healthcare Claims

Pay Rate: $25 to $30/hr. on W2

Job Summary

We are seeking a dedicated Customer Service Representative to join a healthcare organization supporting members, providers, and prospective members. This role is responsible for delivering exceptional customer service, responding to provider and member inquiries, resolving claim-related issues, maintaining accurate documentation, and collaborating with internal departments to ensure timely resolution of inquiries.

The ideal candidate will have strong communication skills, healthcare customer service experience, and the ability to thrive in a fast-paced environment.

Key Responsibilities

• Respond to member and provider inquiries via phone and written correspondence.
• Document all customer interactions accurately in the tracking system.
• Investigate and resolve claim-related inquiries and billing issues.
• Process complaints and ensure timely follow-up and resolution.
• Assist members with Primary Care Provider (PCP) selection and demographic updates.
• Provide benefit and service information to members, providers, and prospective members.
• Coordinate with Claims, Provider Relations, Medical Management, and Member Services to resolve complex issues.
• Perform claim adjustments for overpayments and underpayments.
• Respond to written provider inquiries while maintaining accurate records.
• Handle provider roster updates, disenrollment requests, and utilization management inquiries.
• Conduct member orientations and outreach activities.
• Participate in special projects and claim status investigations.
• Maintain professionalism while handling escalated or challenging customer interactions.

Required Qualifications

• High School Diploma or GED required.
• Minimum of 1 year of experience in a call center, customer service, or healthcare-related environment.
• Experience working in health insurance, a medical office, physician practice, hospital, or healthcare clinic preferred.
• Strong written and verbal communication skills.
• Excellent customer service and problem-solving abilities.
• Strong attention to detail and organizational skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency with Microsoft Office applications.
• Experience with claims processing systems is a plus.

Preferred Skills

• Healthcare claims or insurance experience.
• Knowledge of provider relations and claims adjudication.
• Data entry and documentation experience.
• Ability to collaborate effectively across multiple departments.
• Professional, patient-focused communication skills.

Pride Global offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts.

Pride Global and its affiliates are an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.