XO Health Healthcare Support Representative

XO Health believes healthcare is fixable. Become a part of the community changing the face of the industry. XO Health is the first health plan designed by and for self-insured employers that delivers a more unified health experience for everyone-from those who received care, to those who deliver it, to those who pay for it. We are growing a multi-disciplinary team of diverse and digitally empowered employees ready to rebuild trust in healthcare through comprehensive and unified transformation.

About the Role:

Remote- USA, India -Virtual Contact Center and Claims Operations

The Operations Specialist is a key member of XO Health’s operations team, supporting both member/provider service (Advocacy) and claims processing and resolution (Claims Operations).

This blended role serves as a primary point of contact for members and providers through an omni-channel environment (phone, email, chat), while also functioning as a claim’s operations expert responsible for accurate claim processing, research, adjudication, adjustments, and issue resolution.

This position requires a strong service-first mindset, high attention to detail, and the ability to move seamlessly between real-time support and behind-the-scenes operational work. The Operations Specialist partners cross-functionally with internal teams and third-party vendors to ensure members and providers receive timely, compliant, and high-quality support across the operations.

Key Responsibilities:

Member & Provider Advocacy

• Handle inbound and outbound member and provider inquiries via phone, email, and chat with professionalism and empathy.
• Initiative member outreach to provide information and assistance regarding benefits.
• Provide accurate information regarding benefits, eligibility, and coverage; claims status and adjudication details; prior authorization requirements and submissions; billing and reimbursement policy questions; and provider portal navigation and support.
• Resolve inquiries, complaints, grievances, and escalations promptly while ensuring complete documentation and proper routing when needed.
• Conduct follow-up outreach to ensure resolution, satisfaction, and continuity of care or claim outcomes.
• Build trust with members and providers through early, frequent, and personalized engagement.

Claims Processing, Adjudication & Resolution

• Process, research, and adjudicate institutional and professional medical claims (including behavioral health), ensuring accuracy, timeliness, and compliance.
• Verify eligibility, coverage, and medical necessity under policy guidelines using established systems and workflows.
• Investigate and resolve claim denials, appeals, discrepancies, overpayments, and billing errors and payment issues.
• Conduct overpayment reviews, coordinate recovery actions, and correct claim financial histories as required.
• Support high-cost claim and claimant processes as needed.

Provider Data, Outreach & Operational Support

• Perform provider outreach as necessary to support claims resolution, documentation needs, and payment accuracy.
• Collect W-9s and maintain accurate provider information within XO systems to support claims processing, reporting, directory publication, and data transfers.

Cross-Functional Collaboration & Continuous Improvement

• Collaborate with Business Operations, Network Performance, Product, and Experience teams to resolve complex cases and improve service delivery.
• Coordinate with third-party claims vendors to maintain accuracy, compliance, and service excellence.
• Identify recurring issues, system gaps, or process inefficiencies and provide feedback to leadership.
• Perform quality assurance reviews to ensure claims financial and procedural accuracy.
• Document procedures, workflows, and operational guidance as needed.

Performance & Compliance Expectations

• Meet performance goals in areas such as efficiency and productivity, quality and accuracy, customer satisfaction, compliance, follow-up completion, and attendance.
• Maintain confidentiality and compliance with HIPAA, ERISA, and XO Health policies.

Experience Required:

The qualified candidate will have:

• 3–5 years of experience in a healthcare payer, TPA, or health insurance environment, with a blend of contact center/member-provider support and/or medical claims processing/adjudication/claims operations.
• Strong knowledge of health insurance concepts, benefits and eligibility, medical terminology, and claims lifecycle management.
• Strong English language verbal and written communication skills, with an empathetic, solution-oriented approach.
• High attention to detail, sound judgment, and strong analytical problem-solving skills.
• Ability to multitask in a fast-paced, digital-first environment while maintaining accuracy and professionalism.
• Proficiency in Microsoft Office Suite and customer service and/or claims processing systems.

Preferred Skills:

• Associate or bachelor’s degree in healthcare administration, business, or a related field.
• Experience with consolidated billing/payment platforms and/or alternative payment models (bundled payments).
• Familiarity with Availity Essentials, payer portals, and EDI standards.
• Familiarity with Genesys and Service Now , and other CRM tools
• Familiarity with Facility, DME, Behavioral Health, and Stop-Loss claim types.
• Experience in payment integrity, provider relations, or medical billing.
• Spanish language proficiency (written and verbal) is a plus.

Additional Details:

• Must be able to support USA contact center hours.
• Must be able to participate in a rotating on-call schedule for urgent member and provider support needs.