Job Description

Job Description

Job Title: Healthcare Claims Call Center Associate

Location: Irving, TX (5 days onsite)

Position Summary:

We are seeking dedicated and customer-focused Call Center Agents to handle inbound and outbound calls from Providers and Members as part of our Third Party Administrative (TPA) services. The role involves assisting healthcare providers, members, and prospective beneficiaries with inquiries related to benefits, claims, eligibility, authorizations, and CMS compliance-driven support, ensuring a high-quality experience aligned with CMS guidelines and STAR rating requirements.

Key Responsibilities:

• Handle inbound calls from healthcare providers regarding claim status, billing inquiries, network participation, and pre-authorization submissions.
• Manage member inquiries related to benefits, eligibility, enrollment, and claims.
• Support prospective beneficiary calls during CMS secret shopper tests ensuring compliance with STAR rating requirements.
• Document all call details accurately in the CRM system.
• Adhere to all HIPAA and CMS compliance standards during every interaction.
• Provide accurate and timely information, escalating complex issues to appropriate teams.
• Utilize certified interpreter services for non-English calls to meet CMS language requirements.
• Participate in ongoing training sessions to maintain current knowledge of CMS regulations, plan benefits, claims processes, and compliance protocols.
• Meet or exceed performance standards including Call Quality (98%), Average Handle Time (AHT), First Call Resolution (FCR), and adherence to schedules.
• Collaborate with compliance and quality teams to support continuous improvement and CMS audit readiness.

Qualifications & Skills:

• High School Diploma or GED (required); associate or bachelor’s degree preferred.
• Minimum 1–2 years of call center experience in healthcare claims adjudication .
• Familiarity with CMS guidelines, STAR ratings, and healthcare claims processes .
• Strong verbal and written communication skills with a customer-centric approach.
• Ability to multitask in a fast-paced, high-volume contact center.
• Proficiency in CRM and call center telephony systems.
• Bilingual capability (English + Spanish or any CMS threshold language) is a plus.
• Must be detail-oriented with strong problem-solving and empathy skills

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