Claims Research & Resolution Representative

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Claims Research & Resolution Representative based in the United States.

This remote role is an opportunity to combine customer service, claims research, and problem-solving within a large healthcare environment.
You will investigate claims and claims-related financial issues while supporting members, providers, insurance partners, and other stakeholders.
The position involves handling inbound inquiries, conducting follow-up, researching information across multiple systems, and resolving moderately complex issues.
You will use your judgment to interpret policies, prioritize competing tasks, and determine appropriate resolutions with limited supervision.
The role offers structured training, cross-functional learning, and opportunities to strengthen your healthcare claims and customer service expertise.
Success requires strong organization, technical confidence, confidentiality, and the ability to communicate clearly in a remote call-center setting.
You will play an important role in helping customers and providers navigate claims questions and reach timely, accurate resolutions.

• Handle inbound calls from members, providers, insurance companies, and other stakeholders, addressing questions and resolving claims-related issues.
• Research and resolve moderately complex claims inquiries, including financial recovery, overpayment, and other claims-related matters.
• Conduct outbound calls when necessary to follow up on cases, gather additional information, or facilitate resolution.
• Document inquiries, complaints, transactions, interactions, research findings, and actions taken accurately within internal systems.
• Investigate pending claims and inquiries using available internal resources, systems, policies, and reference tools.
• Escalate unresolved or pending issues appropriately while maintaining ownership of the customer experience.
• Interpret departmental policies, procedures, and established methods to determine appropriate courses of action.
• Exercise independent judgment within defined guidelines when prioritizing workload, managing cases, and determining appropriate resolutions.
• Manage multiple and competing priorities while maintaining productivity, accuracy, and service-quality standards.
• Cross-train across departmental functions and develop proficiency in multiple claims-related processes.
• Maintain strict confidentiality when handling protected health information and other sensitive customer or claims data while working remotely.
• Participate fully in required virtual training and the initial appraisal period to develop proficiency across systems, policies, and processes.

Requirements:

• At least 1 year of call-center or telephone-based customer service experience gained within the past 5 years.
• Previous healthcare-related work experience or education.
• Basic proficiency with Microsoft Office applications, including Word, Excel, Outlook, and Teams.
• Strong technical skills and the ability to navigate and work across multiple software systems simultaneously.
• Ability to independently research and resolve issues using internal system resources and available knowledge tools.
• Strong time-management and prioritization skills, with demonstrated ability to manage multiple or competing priorities.
• Self-reliant and adaptable approach, with the ability to work effectively with minimal supervision.
• Strong communication and customer service skills, particularly in a telephone-based environment.
• Ability to maintain confidentiality and appropriately safeguard protected health information (PHI/HIPAA) while working from home.
• Willingness to complete up to 8 weeks of virtual training, Monday through Friday from 8:00 AM to 4:30 PM Eastern Time, with full attendance expected during training.
• Ability to work an assigned 8-hour shift between 8:00 AM and 6:00 PM Eastern Time following training.
• Willingness to remain in the position for at least 12 months before applying for other internal opportunities.
• A bachelor's degree is preferred.
• Prior claims processing, overpayment, or financial recovery experience is advantageous.
• Experience with Mentor, PrePay, Post Pay, CAS, CIS, CISPRO, or CRM systems is a plus.
• Reliable home internet connection with at least 25 Mbps download and 10 Mbps upload speeds.
• Access to a dedicated, interruption-free workspace suitable for protecting confidential health and customer information.
• Ability to travel occasionally to an office location for training or meetings if required.

Benefits:

• Annual salary: $40,000–$52,300, with individual compensation varying based on location, skills, experience, education, certifications, and other job-related factors.
• Full-time schedule of 40 hours per week.
• Fully remote work opportunity within the United States.
• Comprehensive medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, company holidays, and personal holidays.
• Paid parental and caregiver leave.
• Short-term and long-term disability coverage.
• Life insurance.
• Professional development and continued education opportunities.
• Structured virtual onboarding and training of up to 8 weeks.
• Cross-training across departmental functions to broaden claims and operational expertise.
• Potential overtime opportunities based on business needs.
• Opportunity to develop experience in healthcare claims, customer resolution, financial recovery, and claims operations.
• Remote-work flexibility supported by established technology and work-from-home requirements.

How Jobgether works:

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

Why Apply Through Jobgether?

Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.

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