Summary

The Claims Resolution Specialist is responsible for ensuring accurate, timely, and compliant resolution of medical claims, balance billing issues, and reimbursement requests. This role serves as a key liaison between members, providers, and internal teams to protect members from inappropriate financial liability, including compliance with the No Surprises Act (NSA) and applicable state balance billing laws. The position requires strong analytical skills, detailed claims review, provider and member communication, and a commitment to delivering exceptional member experience.

Essential Duties and Responsibilities

Claims Review, Adjudication & Resolution