Claims Inquiry Representative

Claims Inquiry Representative Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members. 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. Essential duties and responsibilities include the following: 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 Qualification requirements to perform this job successfully include the following: High school diploma or equivalent required; associate or bachelor's degree preferred. Minimum 2 years of healthcare claims, provider services, customer service, or managed care experience preferred. 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. Other skills and abilities include: 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. Benefits include: 401(k) Dental Insurance Health Insurance Life Insurance Vision Insurance Paid Time Off Physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to sit and complete work while on a computer. The employee occasionally is required to stand, walk, use hands to finger, handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, talk and hear. While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Astiva Health, Inc