Claims Resolution Specialist

Pay range $23 – $30 hourly

Employment Full-Time

Location In-Office (Costa Mesa, CA)

Department Claims Resolution

Job Purpose

Ensuring timely and accurate claim follow-up, denial resolution, and appeal submission while monitoring BPO agents performance through daily guidance, quality reviews, and training. Ensure claim activity meets payer requirements and contributes to overall department efficiency.

Duties & responsibilities

• 01If needed, maximize productivity while performing timely claim follow-up via phone and portals, resolving denials, statusing claims, and drafting appeals.
• 02Monitor and support BPO agents handling claim statusing and denial resolution, providing daily guidance, productivity monitoring, and alignment with departmental standards.
• 03Handles high-level escalations for BPO agents.
• 04Audit BPO claim work for accuracy, completeness, and compliance, identifying training gaps or errors for corrective action.
• 05Provide training for new hires and lead refresher sessions as needed, supporting BPO development through material and coaching.
• 06Track BPO KPIs and report underperformance to the Director and Lead to assist in action plans.
• 07Ensure documentation of all claim-related actions in Jira and CollaborateMD, including updates, payer responses, reimbursement, and escalation notes.
• 08Maintain up-to-date knowledge of payer requirements, authorization rules, and communication standards to ensure accurate claims processing.
• 09Engage in team and interdepartmental meetings to troubleshoot issues, identify denial trends, and recommend process improvements.
• 10Communicate department needs and performance concerns to the Director and lead while supporting accountability and development.
• 11Participate in the department's L10 meetings, identify and bring issues, and develop and execute To-Dos and quarterly rocks to drive alignment and improvements toward Cipher VTO.
• 12Performs other related duties as assigned.

Minimum Qualifications

• 01High School Diploma or equivalent
• 022 years' professional experience
• 031 year minimum of management and/or healthcare experience
• 04EOS knowledge/understanding — preferred
• 05Proficient in Atlassian products (Jira & Confluence) — preferred