Healthcare Support Representative

Responsibilities

• Handle inbound and outbound member and provider inquiries via phone, email, and chat with professionalism and empathy.
• Initiative member outreach to provide information and assistance regarding benefits.
• Provide accurate information regarding benefits, eligibility, and coverage; claims status and adjudication details; prior authorization requirements and submissions; billing and reimbursement policy questions; and provider portal navigation and support.
• Resolve inquiries, complaints, grievances, and escalations promptly while ensuring complete documentation and proper routing when needed.
• Conduct follow-up outreach to ensure resolution, satisfaction, and continuity of care or claim outcomes.
• Build trust with members and providers through early, frequent, and personalized engagement.
• Process, research, and adjudicate institutional and professional medical claims (including behavioral health), ensuring accuracy, timeliness, and compliance.
• Verify eligibility, coverage, and medical necessity under policy guidelines using established systems and workflows.
• Investigate and resolve claim denials, appeals, discrepancies, overpayments, and billing errors and payment issues.
• Conduct overpayment reviews, coordinate recovery actions, and correct claim financial histories as required.
• Support high-cost claim and claimant processes as needed.
• Perform provider outreach as necessary to support claims resolution, documentation needs, and payment accuracy.
• Collect W-9s and maintain accurate provider information within XO systems to support claims processing, reporting, directory publication, and data transfers.
• Collaborate with Business Operations, Network Performance, Product, and Experience teams to resolve complex cases and improve service delivery.
• Coordinate with third‑party claims vendors to maintain accuracy, compliance, and service excellence.
• Identify recurring issues, system gaps, or process inefficiencies and provide feedback to leadership.
• Perform quality assurance reviews to ensure claims financial and procedural accuracy.
• Document procedures, workflows, and operational guidance as needed.
• Meet performance goals in areas such as efficiency and productivity, quality and accuracy, customer satisfaction, compliance, follow‑up completion, and attendance.
• Maintain confidentiality and compliance with HIPAA, ERISA, and XO Health policies.

Requirements

• 3–5 years of experience in a healthcare payer, TPA, or health insurance environment, with a blend of contact center/member-provider support and/or medical claims processing/adjudication/claims operations.
• Strong knowledge of health insurance concepts, benefits and eligibility, medical terminology, and claims lifecycle management.
• Strong English language verbal and written communication skills, with an empathetic, solution‑oriented approach.
• High attention to detail, sound judgment, and strong analytical problem‑solving skills.
• Ability to multitask in a fast‑paced, digital‑first environment while maintaining accuracy and professionalism.
• Proficiency in Microsoft Office Suite and customer service and/or claims processing systems.

Core Competencies

Demonstrates expertise in healthcare payer operations, including claims processing, member and provider support, and compliance with regulations such as HIPAA and ERISA. Proficient in managing inquiries and resolving issues with a focus on accuracy, customer satisfaction, and operational efficiency.

Tools & Technologies

• Claims Processing Systems
• Customer Service Software
• XO Systems
• Microsoft Office Suite