Claims Resolution Specialist

Summary

The Claims Resolution Specialist ensures that health plan members are not improperly balance billed by healthcare providers. This role serves as a key liaison between members providers and internal departments to resolve billing discrepancies educate providers on billing requirements and ensure compliance with federal and state balance billing protections including the No Surprises Act (NSA). The specialist is responsible for prompt and accurate resolution of claim-related issues while maintaining a strong focus on member experience and satisfaction.

Essential Duties and Responsibilities

• Investigate and resolve member balance billing issues by coordinating with providers facilities and internal teams.

• Review claims to confirm appropriate processing payment responsibility and benefit application.

• Communicate directly with providers and members to clarify insurance coverage benefits and payment responsibilities.

• Identify trends in billing errors or provider non-compliance and escalate recurring issues to management.

• Document all case activity accurately and promptly in the claims or CRM system.

• Educate providers on proper billing practices and health plan policies related to balance billing.

• Ensure adherence to applicable federal and state balance billing regulations and consumer protection laws.

• Collaborate cross-functionally with claims provider relations and member services to resolve complex cases efficiently.

• Handle sensitive member interactions with professionalism empathy and discretion.

• Uphold a strong focus on member advocacy ensuring that members are protected from inappropriate financial liability.

• Meet or exceed department performance standards for quality timeliness and member satisfaction.

Qualifications

Required:

• 1 year of experience in healthcare billing claims resolution or health plan operations.

• Understanding of PPO EPO and other health plan benefit structures.

• Excellent written and verbal communication skills with strong abilities in negotiation and customer service.

• Excellent attention to detail and ability to research and analyze claim documentation.

• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.

• Proficiency with Google Workspace or Microsoft Office tools.

Preferred:

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

• Experience working with providers and members to resolve billing disputes.

• Familiarity with medical terminology and claim adjudication processes.

• Previous experience with claims platforms or CRM systems.

Soft Skills

• Strong problem-solving and conflict-resolution abilities.

• Empathetic and service-oriented communication style.

• Adaptable and able to work independently or collaboratively within a team.

• Maintains composure and professionalism in escalated situations.

Education

• High School Diploma or GED required.

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

Work Environment / Telecommuting Requirements

• Must maintain a secure private workspace compliant with HIPAA standards.

• Reliable high-speed internet connection required for remote work.

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