Claims Associate

Claims Advocate

At Health Advocate, we're on a mission to simplify healthcare and empower our members to navigate their benefits with confidence. If you're passionate about problem-solving and creating positive outcomes for others, this is your opportunity to make a meaningful impact.

As a Claims Associate, you'll do more than resolve billing issues—you'll be a trusted resource for members, helping them understand their benefits, navigate complex claims, and find resolutions. Your attention to detail and commitment to exceptional service will transform challenges into solutions and build trust with every interaction.

Basic Function

Responsible for handling assigned cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers, and members; research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue; assist members with setting up payment arrangements which may include reaching out to healthcare providers to determine payment options and discussing options with supervisor; exercise exceptional customer service skills in an effort to optimize each contact with the member.

Major Job Accountabilities

Claims Associate Functions - Provide first-line assistance for member's questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures

• Handle assigned cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers, and members
• Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance
• Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue
• Assist members with setting up payment arrangements which may include reaching out to healthcare providers to determine payment options and discussing options with supervisor
• Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical coverage)
• Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues
• Exercise exceptional customer service skills in an effort to optimize each contact with the member
• Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations
• Know and support approved departmental and corporate policies and procedures relating to claims issues

Claims Research Assistance - Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner

• Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue
• As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained
• Follow claims research through until resolution
• Document all claims issues thoroughly maintaining department files and appropriate databases
• Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services
• Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels

Team Interfaces/Customer Service - Establish and maintain a professional relationship with internal/external customers, team members and department contacts

• Cooperate with team members to meet goals or complete tasks
• Provide quality customer service that exceeds customer expectations and improves level of service being provided
• Treat all internal/external customers, team members and department contacts with dignity/respect
• Escalate to supervisor any situation outside the employee's control that could adversely impact the services being provided

Mental and Physical Requirements

• This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers with a workspace that is free and clear of interruptions and distractions.
• The nature of the work in this position is sedentary and the incumbent will be sitting most of the time.
• Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day
• Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day

Related Duties as Assigned

• The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents
• Consequently, job incumbents may be asked to perform other duties as required
• Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above
• Please contact your local Employee Relations representative to request a review of any such accommodations

Minimum Qualifications

Applicant for this job will be expected to meet the following minimum qualifications.

Education

• High School Degree or GED required
• Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred.

Experience

• Minimum of one year customer service, healthcare, or claims experience required.

Other

• Basic Knowledge of MS Word and Excel required
• Must score acceptably on job related testing
• Ability to pass standardized interview
• Based on program may need to be bilingual in English, Spanish, etc.

Knowledge of the following is preferred:

• Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison)
• Consolidated Omnibus Budget Reconciliation Act (COBRA)
• Medicare (Part A, Part B, Part D, Advantage and MediGap Plans)
• Compare and contrast benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods)
• Group Benefits (Fully Insured vs. Self-Insured)
• Medical Benefits (CDHP/HDHP, PPO, POS, and HMO Plans)
• Pharmacy Benefits
• Vision Benefits
• FSA/HSA and HRA Benefits
• Long Term and Short Term Disability and Long Term Care
• Individual Health Plans
• Short Term Plans

Physical Requirements: This position is primarily sedentary, requiring prolonged sitting while performing administrative tasks. The role involves extensive use of a computer for typing, mouse navigation, and reading information on a screen for extended periods. Frequent phone use is required for communication with team members, clients, or external parties. Essential physical functions include fingering, grasping, pulling hand-over-hand, and repetitive motions necessary for navigating software, entering data, and interacting with electronic documents.

Mental and Cognitive Requirements: The role requires strong concentration, attention to detail, and the ability to complete tasks accurately. Critical thinking and problem-solving skills are essential to address issues that may arise in day-to-day duties. Effective verbal and written communication skills are needed for responding to inquiries and collaborating with others.

Work Environment: This position is fully remote and requires a home office environment with appropriate lighting, a computer, and phone access. The workspace should be free from distractions to ensure effective focus and productivity during work hours.

Company Overview

Health Advocate is the nation's leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained