Claims Research & Resolution Representative

Role Overview

This opportunity is being shared on behalf of a partner employer that oversees its own application process and follow-up steps. The opening is for a Claims Research & Resolution Representative in the United States.

The role is a key part of claims operations, focused on careful review, fact-finding, and resolution of complex claim questions. You will support customers and providers by investigating issues, validating claim details, and working toward accurate outcomes across a range of healthcare situations. Success in this role depends on sharp analytical ability, strong attention to detail, and the confidence to interpret policies and procedures correctly. You will work with insurance partners, providers, and members to close disputes efficiently while staying aligned with confidentiality and regulatory expectations. The position offers a meaningful chance to influence fair and timely claims handling.

Core Responsibilities

• Own the full cycle of claim research, investigation, and resolution work.
• Examine claim information, spot inconsistencies, and decide the appropriate next step or outcome.
• Coordinate with members, providers, and insurance carriers to resolve claim-related concerns.
• Use policies, procedures, and compliance rules to support correct claim decisions.
• Authorize or suggest claim settlements within the assigned level of authority.
• Keep thorough case notes, preserve records, and help ensure claims are closed on time.
• Protect sensitive information and follow healthcare privacy and data-security standards.
• Balance several claims at once while keeping work accurate and meeting deadlines.

Requirements

• At least 1 year of experience in a call center, customer service, or similar support environment.
• Prior exposure to healthcare claims processing is preferred.
• Familiarity with medical terminology and insurance workflows is an advantage.
• A bachelor’s degree is considered a plus.
• Capability to interpret data and apply policy rules to real claim situations.
• Clear verbal and written communication skills, along with strong relationship-building ability.
• Very strong attention to detail and comfort handling confidential information.
• Ability to work independently with minimal oversight.
• Intermediate-level math and analytical capability.

Benefits and Perks

• Competitive yearly compensation aligned to experience and location.
• Coverage for medical, dental, and vision insurance.
• 401(k) retirement savings option.
• Paid time away from work, including holidays, vacation time, and sick leave.
• Paid leave for parental and caregiver needs.
• Short-term and long-term disability protection.
• Life insurance coverage.
• Remote work setup with support for internet requirements.
• Room for career growth in a healthcare-centered organization.

Additional Information

The hiring process may involve AI-assisted screening tools, but human reviewers make the final hiring decisions. Personal data may be processed to evaluate candidacy and shared with the employer as part of pre-contract and legitimate-interest processing, subject to applicable data protection laws. Applicants may request access, correction, deletion, or objection regarding their data where permitted by law.