Claims Specialist, COE

Relation Insurance Services; United States; On-site; USD 30,000 - 52,000; Full time

Benefits offered by this job

Competitive pay

Benefits package incl. 401K and health

Paid time off

Paid holidays

Career development opportunities

Job summary

Relation Insurance Services is seeking a Claims Specialist to manage Healthcare COE claims, ensuring accuracy, timeliness, and HIPAA compliance across programs. You will investigate discrepancies, support members, coordinate with Smart Care Centers and clients, and drive continuous improvement using our internal systems and AI-enabled tools.

Successful candidates bring at least three years in healthcare claims processing and strong communication, detail orientation, and collaborative problem

Qualifications

• High School diploma or equivalent is required.
• Minimum of 3 years in healthcare claims processing or related operations.
• Experience supporting COE programs, TPAs, or self-funded health plans preferred.
• Experience in member services or provider relations within a healthcare environment preferred.
• Working knowledge of healthcare regulations, reimbursement guidelines, and industry standards preferred.
• Experience working with claims reporting, reconciliation, or quality assurance processes preferred.
• Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment.
• Effective problem-solving, organizational, and analytical skills.
• Strong written and verbal communication skills with the ability to interact professionally with members, clients, and providers.
• Proficiency in Microsoft Office Suite and claims processing systems or similar healthcare platforms, with the ability to learn new software/systems.
• Ability to handle sensitive information in compliance with HIPAA confidentiality regulations.

Responsibilities

• Process COE claims accurately and timely in accordance with established procedures and program requirements.
• Review, research, and resolve claims discrepancies, payment issues, and escalations with high accuracy.
• Serve as a subject matter resource for claims investigations, billing questions, and reimbursement inquiries.
• Coordinate with Smart Care Centers and clients to ensure timely and accurate claims adjudication and payment processing.
• Support members by addressing claims-related questions and concerns with professionalism.
• Conduct auditing, reconciliation, and quality review activities to ensure claims accuracy and reimbursement integrity.
• Collaborate with COE Operations and Clinical teams to ensure claims workflows align with organizational standards and program requirements.
• Maintain accurate claims documentation, payment records, and related reporting data.
• Identify trends, recurring issues, or system gaps and escalate appropriately to support resolution.
• Contribute to continuous improvement initiatives to enhance claims processing efficiency, accuracy, and overall service delivery.
• Leverage internal systems, reporting tools, and proprietary technologies, including AI-enabled solutions, to improve claims processing accuracy, streamline workflows, and enhance issue resolution.

Skills

Attention to detail

Communication skills

Claims processing

Analytical thinking

Multitasking

HIPAA compliance

Education

High School diploma or equivalent

Tools

Microsoft Office

Job description

Who We Are

Relation Insurance is a leading, innovative company with a strong commitment to excellence and a passion for delivering cutting-edge solutions to our clients. As a key player in the insurance market, we pride ourselves on our dynamic culture, collaborative environment, and continuous drive for success. With a rich history and a bright future ahead, we are looking for exceptional individuals to join our team and contribute to our ongoing growth and success.

Who We Are

Relation Insurance is a leading, innovative company with a strong commitment to excellence and a passion for delivering cutting-edge solutions to our clients. As a key player in the insurance market, we pride ourselves on our dynamic culture, collaborative environment, and continuous drive for success. With a rich history and a bright future ahead, we are looking for exceptional individuals to join our team and contribute to our ongoing growth and success.

What We’re Looking For

The Claims Specialist processes and manages claims activities related to the organization’s Healthcare Center of Excellence (COE) programs, ensuring accuracy, timeliness, and compliance with established standards. The individual in this position serves as a key resource for claims investigations, payment discrepancies, billing resolution, and member support. The Claims Specialist collaborates closely with external Smart Care Centers, clients, clinical teams, and internal operations to support efficient claims processing, reimbursement accuracy, and overall program performance.

A GLIMPSE INTO YOUR DAY

• Processes COE claims accurately and timely in accordance with established procedures and program requirements.
• Reviews, researches, and resolves claims discrepancies, payment issues, and escalations with a high degree of accuracy.
• Serves as a subject matter resource for claims investigations, billing questions, and reimbursement inquiries.
• Coordinates with Smart Care Centers and clients to ensure timely and accurate claims adjudication and payment processing.
• Supports members by addressing claims-related questions and concerns with a high level of professionalism service.
• Conducts auditing, reconciliation, and quality review activities to ensure claims accuracy and reimbursement integrity.
• Collaborates with COE Operations and Clinical teams to ensure claims workflows align with organizational standards and program requirements.
• Maintains accurate claims documentation, payment records, and related reporting data.
• Identifies trends, recurring issues, or system gaps and escalates appropriately to support resolution.
• Contributes to continuous improvement initiatives to enhance claims processing efficiency, accuracy, and overall service delivery.
• Leverages internal systems, reporting tools, and proprietary technologies, including AI-enabled solutions, to improve claims processing accuracy, streamline workflows, and enhance issue resolution.
• Performs other projects, duties, and tasks, as assigned.

What Success Looks Like In This Role

• High School diploma or equivalent required.
• Minimum of 3 years of experience in healthcare claims processing, billing, reimbursement, or a related healthcare operations role.
• Experience supporting Centers of Excellence (COE) programs, third-party administrators (TPAs), or self-funded health plans preferred.
• Experience in member services or provider relations within a healthcare environment preferred.
• Working knowledge of healthcare regulations, reimbursement guidelines, and industry standards preferred.
• Experience working with claims reporting, reconciliation, or quality assurance processes preferred.
• Strong understanding of medical claims processes, billing practices, and reimbursement methodologies.
• Experience researching and resolving claims discrepancies, payment issues, and escalated claims concerns.
• Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment.
• Effective problem-solving, organizational, and analytical skills.
• Strong written and verbal communication skills with the ability to interact professionally with members, clients, and providers.
• Proficiency in Microsoft Office Suite and claims processing systems or similar healthcare platforms, with the ability to learn new software/systems.
• Ability to handle sensitive information in compliance with HIPAA confidentiality regulations.

WHY CHOOSE RELATION?

• Competitive pay.
• A safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more.
• Career advancement and development opportunities.

Note:

The above is not all encompassing of the full position description.

Relation Insurance Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Relation, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is presented within this posting.
You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance.
$21.63 - $37.98