Claims Advisor

Our client, a Health Insurance company, is looking for a Claims Advisor for their Remote location.
 
Responsibilities:

• The Account Advisor I is responsible for resolving benefit and claims inquiries from members and providers via telephone and other approved channels within a call center environment.
• This role supports a positive customer experience while ensuring compliance with all applicable laws, regulations, and company policies.
• Individual contributor role; no direct reports
• Reports to: Supervisor, Customer Service
• Operates in a high-volume call center environment, with the majority of time spent on the phone
• Internal: Enrollment & Billing, Claims, Provider Relations, Benefit Operations, Network Administration, Sales/Marketing, Accounting, Medical Management, Pharmacy, Legal
• External: Members, Providers, Brokers, Employers/Groups, Other Insurance Plans, CMS, Social Security Administration
• Handle inbound inquiries related to benefits, claims, billing, and eligibility
• Research and resolve customer issues across multiple systems to ensure accuracy of benefits and payments
• Responding to inquiries regarding adjustments, refunds, and payment discrepancies
• Maintain up-to-date knowledge of policies, procedures, and regulatory requirements
• Document interactions and ensure completeness and accuracy of information
• Meet established customer service performance metrics (quality, productivity, customer satisfaction, attendance)
• Demonstrate ownership of issues and drive First Call Resolution (FCR)
• Perform other duties as assigned within scope

• High-volume call center role supporting members/providers
• Focus on benefits & claims resolution, accuracy, and customer satisfaction
• Requires strong communication, problem-solving, and healthcare knowledge
• Entry-level with 1 year experience or equivalent training
• Performance-driven environment with defined metrics
• High School Diploma or Equivalent Preferred Experience
• 1 year of customer service or medical office experience required
• OR completion of BRCC Medical Assistant, Coding & Insurance pathway in lieu of experience
• Call center experience preferred
• Strong verbal and written communication skills with professionalism and empathy
• Ability to interpret and explain benefits, claims, and policies clearly
• Critical thinking and problem-solving skills
• Ability to multitask and manage multiple inquiries in a fast-paced environment
• Attention to detail and organizational skills
• Conflict resolution and ability to remain calm under pressure
• Active listening and effective questioning skills
• Proficiency in Microsoft Office and related systems
• Familiarity with healthcare/insurance terminology preferred
• Approximately 95% of time spent on phone in a call center environment
• May be required to work during emergencies or inclement weather
• Must successfully complete customer service training and demonstrate proficiency

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities