Why This Role Matters
- As a Claims Operations Specialist, you will play a critical role in ensuring accurate, timely, and compliant resolution of healthcare claims and appeals. Your work directly supports providers, clients, and members by helping resolve claim-related issues, maintaining data integrity, and ensuring claims are processed correctly.
- This role is ideal for someone who enjoys problem-solving, investigating details, and working in a fast-paced environment where accuracy matters.
- You''ll collaborate with clinical teams, coding professionals, customer service partners, and other internal stakeholders to deliver efficient claim outcomes that contribute to operational excellence and an exceptional customer experience.
What You''ll Do
- Review and analyze claim appeals to ensure accurate resolutions while partnering with coding and clinical teams as needed.
- Investigate claim discrepancies and identify solutions that improve claim processing accuracy and customer satisfaction.
- Manage and prioritize claim inventories across inpatient, outpatient, and provider billing workflows to support service and performance goals.
- Research, retrieve, and validate information from internal and external systems to support claim reviews and special projects.
- Maintain accurate provider and claim data through detailed data entry, validation, and database updates.
- Process claim adjustments and corrected claims to ensure appropriate reimbursement and adjudication outcomes.
- Coordinate workflow assignments and support operational continuity when automated distribution processes require manual intervention.
- Collaborate across departments to resolve issues, support business initiatives, and maintain compliance with HIPAA and organizational standards.
What You Will Bring
Required Qualifications
- High school diploma or GED and two (2) years of experience in claims processing, customer service, medical records, collections, data entry, database management, or a related operational role; OR an Associate''s degree with no prior experience required.
- Experience working with business systems, databases, and Microsoft Office applications, including Word and Excel.
- Strong analytical, organizational, problem-solving, and communication skills.
- Ability to prioritize competing demands and adapt quickly in a fast-paced environment.
- Ability to work independently while handling confidential and sensitive information.
- Demonstrated technical aptitude and ability to identify, troubleshoot, and escalate issues appropriately.
Preferred Qualifications
- Experience in healthcare operations, claims administration, or medical records.
- Knowledge of medical terminology, healthcare claims processing, and medical coding concepts.
- Experience supporting claim appeals, provider billing, or reimbursement-related activities.
- Familiarity with healthcare compliance requirements, including HIPAA.
Compensation
The salary range for this position is $45k-$50k. Actual compensation is based on experience, skills, education, work location, and internal equity. This position may also be eligible for incentive compensation and the comprehensive benefits outlined in the My Total Value section.
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Why Claritev?
Healthcare is complex. We help make it clearer.
At Claritev, you''ll do work that matters. Together, we''re helping make healthcare more transparent and affordable for all through the power of data, technology, and expertise. We offer meaningful opportunities to grow your career, collaborate with talented colleagues, and make an impact on the clients and communities we serve. If you''re looking for purpose, growth, and a team that succeeds together, you''ll find it here.
What Guides Us
At Claritev, innovation, agility, and a focus on results drive our success. We embrace bold thinking, work as one team, take ownership, and strive for excellence in everything we do - creating meaningful impact for our clients, communities, and each other.