Claims Resolution Specialist

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.

Job Duties

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

Minimum Qualifications:

• High School Diploma or equivalent
• 2 years’ professional experience .
• 1 Year Minimum of Management and/or Healthcare Experience
• EOS Knowledge/Understanding Preferred
• Proficient in Atlassian Products (Jira & Confluence), Preferred

Pay: $23.00 - $30.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Parental leave
• Vision insurance

Ability to Commute:

• Costa Mesa, CA 92626 (Required)

Work Location: In person