Certified Claims Call Center Processor

Certified Claims Call Center Processor I at All Care Health with the Claims department in Grants Pass, Oregon We Are Seeking Qualified Candidates to Join Our Team!

All Care Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

• competitive wages
• affordable healthcare
• 401k retirement
• wellness programs
• flexible schedule options

The Certified Claims Call Center Processor I serves as a primary point of contact for provider offices and their 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.

The position is responsible for delivering timely, accurate, and professional claim resolutions while supporting positive provider relationships and maintaining departmental quality and production standards.

• Respond to a high volume of inbound provider calls and electronic inquiries while maintaining professionalism, accuracy, and customer service standards.
• Research and resolve provider inquiries by reviewing claim history, claim edits, payment determinations, authorization requirements, coding issues, eligibility information, and applicable policies.
• Process and adjudicate professional claims across multiple lines of business in accordance with established policies, procedures, coding guidelines, and benefit plans.
• Review and resolve claim edits, denials, adjustments, reconsiderations, disputes, and reprocessing requests by analyzing claim data, supporting documentation, and applicable policies to determine appropriate corrective action.
• Evaluate pending and problematic claims to identify root causes of processing issues, including billing errors, coding discrepancies, configuration issues, authorization concerns, coordination of benefits conflicts, eligibility issues, or missing information.
• Coordinate benefits by reviewing member eligibility, payer responsibility, and other insurance coverage information to ensure accurate application of coordination of benefits (COB) guidelines.
• Explain claim determinations, payment methodologies, denial reasons, and processing requirements clearly and professionally to provider offices and authorized representatives.
• Maintain accurate documentation of provider interactions, claim research, and claim resolutions within approved systems and tracking tools.
• Identify recurring claim issues, processing trends, or potential system concerns and elevate 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…