Certified Call Center Claims Processor

Certified Call Center Claims Processor I

Location:

Grants Pass, Oregon, USA

Salary Range: $20.00 to $24.00 hourly

The Certified Claims Call Center Processor I serves as the primary point of contact for provider offices and authorized representatives, responding to inbound calls and electronic inquiries regarding professional and facility claims processing and adjudication. This role combines customer service and certified claims processing responsibilities by independently resolving provider inquiries, researching claim issues, and adjudicating professional claims in accordance with company policy, contract language, coding guidelines, and applicable regulatory requirements.

• Respond promptly and professionally to inbound provider calls, emails, and other inquiries regarding claim status, adjudication outcomes, benefits, pricing, coding, and payment determinations.
• Independently research and resolve professional claim issues by reviewing claim history, coding, benefits, pricing logic, contract language, and applicable system edits.
• Accurately adjudicate professional claims using CPT, HCPCS, ICD‑10 coding guidelines, reimbursement methodologies, benefit plans, and regulatory requirements.
• Maintain accurate and detailed documentation of provider interactions, claim research, resolutions, and claim adjustments within the core claims system and tracking tools.
• Explain claim outcomes, billing requirements, and processing guidelines to providers and their representatives while promoting positive provider relationships.
• Coordinate benefits by reviewing member eligibility, payer responsibility, and other insurance coverage information to ensure accurate application of coordination of benefits guidelines.
• Identify recurring claim issues, processing trends, or potential system concerns and escalates findings as appropriate.
• Communicate and collaborate effectively with providers, members, leadership, and internal departments to support timely and accurate issue resolution.
• Maintain compliance with HIPAA, PHI, claim routing procedures, inventory control standards, quality benchmarks, production expectations, and other applicable policies and regulatory requirements.
• Participate in a rotating call coverage schedule, including primary phone coverage and fill‑in support during breaks, lunches, and periods of increased call volume, while assisting with claims processing as operational needs permit.
• Demonstrate flexibility and teamwork by assisting peers and supporting departmental workflows and operational priorities.
• Participate in ongoing training and continuing education to maintain coding certification and remain current on coding, reimbursement, regulatory, and industry changes.
• Maintain punctual, regular, and predictable attendance.
• Work collaboratively in a team environment and respectfully follow leadership direction.
• Perform other duties as assigned.

• Associate degree (AA) from a two‑year college or technical school required, or an equivalent combination of education and experience.
• Six months to one year of experience in healthcare claims processing, medical billing, provider services, customer service, or a related healthcare administrative role.
• Experience reviewing, researching, and resolving claim‑related issues preferred.
• Experience using healthcare claims processing systems preferred.
• EZ‑CAP experience preferred.
• Current coding certification from the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) required (e.g., CPC, CPC‑P).
• Working knowledge of ICD‑10‑CM, ICD‑10‑PCS, CPT, and HCPCS coding systems.
• Knowledge of CMS‑1500, UB‑04, and other healthcare claim forms.
• Strong organizational and time‑management skills.
• Proficient computer skills, including Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
• Ability to maintain compliance with HIPAA regulations.

Being bilingual in another language, including American Sign Language (ASL), is an invaluable skill that enhances our ability to deliver culturally responsive care and is strongly encouraged.

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