Claims Inquiry Representative

Astiva Health•Orange, CA

8h•$25 - $28•Onsite

About The Position

The Claims Inquiry Representative serves as the primary point of contact for providers, members, and internal departments regarding claim status, payments, denials, adjustments, and billing inquiries. This role investigates claim issues, provides accurate information, and works collaboratively with claims processing, provider services, and other departments to ensure timely resolution of inquiries.

Requirements

High school diploma or equivalent required
Knowledge of medical terminology, CPT, HCPCS, ICD-10, and claims processing.
Familiarity with Medicare Advantage, Medicaid, and commercial health plan operations.
Strong analytical, problem-solving, and customer service skills.
Proficiency in Microsoft Office and claims administration systems.
Excellent verbal and written communication skills.
Attention to detail
Critical thinking
Customer service orientation
Time management
Conflict resolution
Teamwork and collaboration
Professional communication
Frequent telephone and computer use.
Ability to manage multiple inquiries while meeting productivity and quality standards.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before groups and customers or employees of the organization.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

Nice To Haves

associate or bachelor's degree preferred.
Minimum 2 years of healthcare claims, provider services, customer service, or managed care experience preferred.

Responsibilities

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 departmental procedures.
Identify trends and recurring claim issues and escalate when appropriate.
Assist providers with claims submission requirements and billing guidelines.
Maintain compliance with Medicare, Medicaid, Commercial, and organizational policies.
Meet departmental service level standards for call handling and issue resolution.
Regular and consistent attendance
Other duties as assigned