BILINGUAL Claims Research & Resolution Representative

About the position

The Bilingual Claims Research & Resolution Representative 2 plays a crucial role in managing claims operations that involve direct customer contact, thorough investigation, and effective resolution of claims. This position is essential in ensuring that claims are processed accurately and efficiently, contributing to the overall success of the claims department. The representative will engage with various stakeholders, including insurance companies, healthcare providers, members, and collection services, to resolve pending claims and inquiries. This role is situated within a claims inbound call center, where the representative will be part of a dedicated team focused on researching and resolving claims-related issues. In this position, the representative will perform a variety of activities that may include moderately complex administrative tasks and customer support assignments. The role requires a strong ability to interpret policies and procedures while working within defined parameters. Representatives will have some latitude in prioritizing their tasks and will work under minimal supervision, allowing for independent decision-making in line with departmental standards. The representative will follow established policies and practices, which may allow for some interpretation and discretion in handling claims. The Bilingual Claims Research & Resolution Representative 2 is expected to demonstrate strong problem-solving skills, manage multiple priorities effectively, and maintain confidentiality while working remotely. The position requires proficiency in using internal systems and software to find resolutions to issues and respond to inquiries. The representative will also be responsible for performing computations and ensuring that all claims are handled in accordance with company policies and quality standards.

Responsibilities
• Manage claims operations involving customer contact, investigation, and resolution of claims.
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• Engage with insurance companies, providers, members, and collection services to resolve claims.
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• Perform varied activities and moderately complex administrative and customer support assignments.
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• Utilize internal system resources to find resolutions to issues and respond to inquiries.
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• Demonstrate strong time management and prioritization skills to handle multiple competing priorities.
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• Maintain confidentiality while working remotely and protect member PHI/HIPAA information.
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• Follow standard policies and practices while exercising independent discretion when necessary.

Requirements
• 1 or more years of Call Center or Telephonic customer service experience within the past 5 years.
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• Bilingual in Spanish and English.
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• Self-reliant with the ability to resolve issues independently with minimal supervision.
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• Strong technical skills with the ability to work across multiple software systems.
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• Basic Microsoft Office skills (Word, Excel, PowerPoint, and Outlook).
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• Ability to manage multiple or competing priorities effectively.

Nice-to-haves
• Previous health care related experience or education.
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• Bachelor's Degree.
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• Prior claims processing experience.
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• Overpayment experience.
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• Financial recovery experience.
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• Previous experience with Mentor software.
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• PrePay or Post Pay experience.
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• CAS, CIS or CISPRO experience.
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• CRM experience.

Benefits
• Medical, dental, and vision benefits.
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• 401(k) retirement savings plan.
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• Paid time off, including company and personal holidays.
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• Volunteer time off.
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• Paid parental and caregiver leave.
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• Short-term and long-term disability insurance.
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• Life insurance.

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