Claims Associate

LanguageLine Solutions

11d•Remote

About The Position

At Health Advocate, we’re on a mission to simplify healthcare and empower our members to navigate their benefits with confidence. If you’re passionate about problem-solving and creating positive outcomes for others, this is your opportunity to make a meaningful impact. As a Claims Associate, you’ll do more than resolve billing issues—you’ll be a trusted resource for members, helping them understand their benefits, navigate complex claims, and find resolutions. Your attention to detail and commitment to exceptional service will transform challenges into solutions and build trust with every interaction.

Requirements

High School Degree or GED required
Minimum of one year customer service, healthcare, or claims experience required
Basic Knowledge of MS Word and Excel required
Must score acceptably on job related testing
Ability to pass standardized interview
Based on program may need to be bilingual in English, Spanish, etc.

Nice To Haves

Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred
Knowledge of the Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison)
Knowledge of Consolidated Omnibus Budget Reconciliation Act (COBRA)
Knowledge of Medicare (Part A, Part B, Part D, Advantage and MediGap Plans)
Knowledge of comparing and contrasting benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods)
Knowledge of Group Benefits (Fully Insured vs. Self-Insured)
Knowledge of Medical Benefits (CDHP/HDHP, PPO, POS, and HMO Plans)
Knowledge of Pharmacy Benefits
Knowledge of Vision Benefits
Knowledge of FSA/HSA and HRA Benefits
Knowledge of Long Term and Short Term Disability and Long Term Care
Knowledge of Individual Health Plans
Knowledge of Short Term Plans

Responsibilities

Provide first-line assistance for member’s questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures
Handle assigned cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers, and members
Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance
Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue
Assist members with setting up payment arrangements which may include reaching out to healthcare providers to determine payment options and discussing options with supervisor
Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical coverage)
Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues
Exercise exceptional customer service skills in an effort to optimize each contact with the member
Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations
Know and support approved departmental and corporate policies and procedures relating to claims issues
Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner
Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue
As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained
Follow claims research through until resolution
Document all claims issues thoroughly maintaining department files and appropriate databases
Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services
Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels
Establish and maintain a professional relationship with internal/external customers, team members and department contacts
Cooperate with team members to meet goals or complete tasks
Provide quality customer service that exceeds customer expectations and improves level of service being provided
Treat all internal/external customers, team members and department contacts with dignity/respect
Escalate to supervisor any situation outside the employee's control that could adversely impact the services being provided