Claims Resolution Specialist

Curative HR LLC • Austin, TX

1d • $25 - $29 • Remote

About The Position

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.

Requirements

• 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.
• 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.
• High School Diploma or GED required.

Nice To Haves

• 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.
• Associate’s or Bachelor’s degree in Healthcare Administration, Business, or a related field preferred.

Responsibilities

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

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 8–12 weeks paid parental leave, based on role eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED