Claims Inquiry Representative

Description

About Us:

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.

SUMMARY: 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 elevate 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

Requirements

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• 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:

• 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:

• 401(k)
• Dental Insurance
• Health Insurance
• Life Insurance
• Vision Insurance
• Paid Time Off

LANGUAGE: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups and customers or employees of the organization.

MATHEMATICS: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

EEO/AFFIRMATIVE ACTION STATEMENT: It is the policy of Astiva Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law. This policy relates to all phases of employment, including but not limited to recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and termination, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the organization where appropriate. Please refer to Standard Operating Procedure 100 for more information about the organization’s Affir

PHYSICAL DEMANDS: The 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.

WORK ENVIRONMENT: 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.