Claims Resolution Specialist

About Curative

Curative is building the future of health insurance with a first-of-its-kind employer-based plan designed to remove financial barriers and make care truly accessible: one monthly premium with $0 copays and $0 deductibles*. Backed by our recent $150M in Series B funding and valuation at $1.275B Curative is scaling rapidly and investing in AI-powered service deeper member engagement and a smart network designed for todays workforce.

Our north star guides everything we do: healthcare only works when people can actually use it. That belief drives every decision we make: from how we design our plan support our members to how we collaborate as a team.

If you want to do meaningful work with a team that moves fast experiments boldly and cares deeply Curative is the place to do it. Were growing fast and looking for teammates who want to help transform health insurance for the better.

Summary

The Claims Resolution Specialist is responsible for ensuring accurate timely and compliant resolution of medical claims balance billing issues and reimbursement requests. This role serves as a key liaison between members providers and internal teams to protect members from inappropriate financial liability including compliance with the No Surprises Act (NSA) and applicable state balance billing laws. The position requires strong analytical skills detailed claims review provider and member communication and a commitment to delivering exceptional member experience.

Essential Duties and Responsibilities

Claims Review Adjudication & Resolution

• Review analyze and adjudicate medical claims in accordance with plan benefits internal policies and regulatory requirements.
• Confirm member eligibility plan enrollment coordination of benefits (COB) authorizations and benefit limitations.
• Validate accurate coding using ICD-10 CPT HCPCS and revenue codes.
• Identify underpayments overpayments duplicate claims and processing errors; calculate allowable amounts contractual adjustments and interest as required.
• Process claim adjustments reversals reprocessing and corrected claims.

Balance Billing & Regulatory Compliance

• Investigate and resolve member balance billing disputes with providers and facilities.
• Ensure compliance with the No Surprises Act (NSA) and applicable federal and state balance billing and consumer protection regulations.
• Educate providers on appropriate billing practices plan policies and regulatory requirements.
• Escalate recurring provider non-compliance or systemic billing issues to leadership.

Reimbursement & Payment Processing

• Process member and provider reimbursement requests including out-of-network and manual reimbursement submissions.
• Review and validate required documentation receipts and clinical information.
• Ensure reimbursements comply with benefit coverage payment timelines and regulatory standards.
• Prepare and route reimbursement payments for approval with accurate documentation and coding.

Member Provider & Internal Support

• Communicate clearly and professionally with members and providers regarding claim determinations benefits and payment responsibilities.
• Respond to internal and external claim inquiries appeals reconsiderations and dispute requests.
• Collaborate cross-functionally with Claims Provider Relations Member Services and Finance teams to resolve complex cases.
• Handle sensitive or escalated interactions with empathy professionalism and discretion.

Documentation Quality & Process Improvement

• Document claim decisions resolution steps and communications accurately in claims and CRM systems.
• Meet or exceed departmental productivity quality and timeliness standards.
• Identify trends system issues or process gaps and provide recommendations for improvement.
• Participate in training meetings and continuing education to maintain current knowledge of policies and regulations.
  .

Additional Responsibilities

• Adhere to all HIPAA confidentiality and compliance requirements.
• Maintain a secure remote work environment.
• Perform additional duties and special projects as assigned by leadership.

Qualifications

Required:

• 1 year of experience in healthcare claims processing billing reimbursement or claims resolution.

• Working knowledge of PPO EPO and other health plan benefit structures.

• Strong analytical and problem-solving skills with high attention to detail.

• Excellent written and verbal communication skills with the ability to interact professionally with members and providers.

• Proficiency in Google Workspace and/or Microsoft Office (Excel/Sheets required).

• Ability to manage multiple priorities in a fast-paced deadline-driven environment.

Preferred:

• Knowledge of the No Surprises Act (NSA) and relevant state-level balance billing regulations.

• Experience with medical coding (ICD-10 CPT HCPCS) and claim adjudication rules preferred.

• Familiarity with claims processing platforms and CRM systems (HealthEdge HealthRules Payer System a plus).

• Prior experience handling provider disputes underpayments and reimbursement requests..

Skills & Competencies

• Strong customer service and member advocacy mindset.

• Effective negotiation and conflict resolution abilities.

• Ability to work independently while collaborating within a team environment.

• Maintains composure in escalated or high-volume situations.

• Strong computer skills and ability to work at a computer for extended periods.

Education

• High School Diploma or GED required.

• Associates or Bachelors degree in Healthcare Administration Business or a related field preferred.

Work Environment / Telecommuting Requirements

• Remote position requiring a secure private workspace compliant with HIPAA standards.

• Reliable high-speed internet connection required.

• Minimal travel may be required for training or meetings (less than 5%).

Perks & Benefits

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.)
  • $0 copays and $0 deductibles (with completion of our Baseline Visit )
  • Preventive and primary care built in
  • Mental health support (Rula Televero Two Chairs Recovery Unplugged)
  • One-on-one care navigation
  • Chronic condition programs (diabetes weight hypertension)
  • Maternity and family planning support
  • 24/7/365 Curative Telehealth
  • Pharmacy benefits
• Comprehensive dental and vision coverage
• Employer-provided life and disability coverage with additional supplemental options
• Flexible spending accounts
• Flexible work options: remote and in-person opportunities
• Generous PTO policy plus 11 paid annual company holidays
• 401K for full-time employees
• Generous Up to 812 weeks paid parental leave based on role eligibility.