Healthcare Claims Resolution Specialist

Astiva Health; Orange (CA); Hybride; USD 42 000 - 65 000; Plein temps

Avantages offerts par ce poste

401(k)

Dental Insurance

Health Insurance

Life Insurance

Vision Insurance

Paid Time Off

Résumé du poste

Astiva Health, Inc. in Orange, CA, seeks a Claims Inquiry Representative to be the primary contact for providers, members, and internal teams regarding claim status, payments, denials, adjustments, and billing inquiries.

You will investigate issues, provide accurate information, and collaborate with multiple departments to resolve inquiries promptly. Responsibilities include researching discrepancies, explaining adjudication outcomes, reviewing EOBs, and ensuring compliance with Medicare,

Qualifications

• High school diploma or equivalent required; associate or bachelor's degree preferred.
• Minimum 2 years of healthcare claims, provider services, customer service, or managed care experience preferred.
• Knowledge of medical terminology, CPT, HCPCS, ICD-10, and claims processing.
• Familiarity with Medicare Advantage, Medicaid, and commercial health plan operations.

Responsabilités

• Respond to provider and member inquiries regarding claim status, payment, denials, adjustments, and reimbursement.
• Research and resolve claim discrepancies using claims processing systems and supporting documentation.
• Explain claim adjudication outcomes, payment methodologies, and applicable policies.
• Review Explanation of Benefits (EOBs), remittance advices, and claim records.
• Coordinate with Claims, Provider Services, Finance, Utilization Management, and other departments to resolve complex issues.
• Document all inquiries and actions taken in accordance with procedures.
• Identify trends and recurring claim issues and elevate when appropriate.
• Assist providers with claims submission requirements and billing guidelines.

Connaissances

Analytical skills

Problem solving

Customer service

Attention to detail

Critical thinking

Time management

Conflict resolution

Teamwork

Professional communication

Telephone and computer use

Formation

High school diploma or equivalent

Associate or bachelor's degree preferred

Outils

Microsoft Office

Claims administration systems

Description du poste

Astiva Health, Inc. in Orange, CA, seeks a Claims Inquiry Representative to be the primary contact for providers, members, and internal teams regarding claim status, payments, denials, adjustments, and billing inquiries.

You will investigate issues, provide accurate information, and collaborate with multiple departments to resolve inquiries promptly. Responsibilities include researching discrepancies, explaining adjudication outcomes, reviewing EOBs, and ensuring compliance with Medicare,