The Claims Customer Service Analyst is responsible for managing and resolving claims-related inquiries and escalations with a strong focus on accuracy, compliance, and provider satisfaction. This role requires advanced knowledge of claims adjudication, coding, billing standards, and regulatory requirements. The analyst collaborates closely with internal departments and external providers to ensure timely and accurate claims processing and resolution.
Key Responsibilities:
- Serves as the first point of contact for providers with questions about claims and the breakdown of payments.
- Oversee adverse claims escalations/disputes/reconsiderations process.
- Answers escalated provider tickets/calls and escalations in collaboration with the Network team per team standards
- Analyzes/Strategizes long term solutions for applicable claim inaccuracies identified and alerts Claims Leadership/Networks as applicable.
- Reprocess and re-export of claims; resolve medical billing discrepancies in accordance with tango’s Provider Manual.
- Interpret and apply HIPAA guidelines, contracts, and fee schedules; educate internal staff and providers as needed.
- Utilize coding/authorization knowledge (CPT, HCPCS, HIPPS) to assess dispute validity and support claim adjudication.
- Handle inbound and outbound calls with providers, offering resolution and guidance.
- Educate providers verbally and electronically on EDI transmission errors and clean claims submission practices.
- Manage and respond to claims documentation requests in a timely manner.
- Monitors/Maintains Plexis Alerts (process of EOP distribution) after each claim run.
- Collaborate with Networks on high-volume denial/rejection claims, developing plans for improved submission.
- Participate in monthly Claims Webinars and provider training sessions.
- Ability to consistently meet productivity and quality standards
Essential Functions
- Review escalated ticket/inbound and outbound call inventory and audit findings (external and internal) to maintain compliance with company policies.
- Manage escalated claims issues and provider concerns promptly and professionally.
- Working in Power BI, PCM, Tempo, Freshdesk and Elevate.
Qualifications
Experience & Knowledge
- 3-5 years minimum experience in Medical Billing and Coding claims processing.
- 1-3 years of experience in a healthcare call center, health insurance, medical office or claim processing environment.
- Strong knowledge of claims processes, benefits and billing procedures.
- Proficient with call center software (e.g., Avaya, Elevate, Cisco) and CRM systems
- Strong knowledge of HIPPS, CPT, and HCPCS coding systems.
- Familiarity with eligibility, authorization and claims submission standards across multiple lines of business.
- Experience supporting system testing, enhancements, and data portals.
Education & Training
- Professional-level training or certification in claims processing, healthcare administration, or related fields preferred.
Skills & Abilities
- Advanced proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint).
- Strong interpersonal, written, and verbal communication skills.
- Proven self-starter, analytical, research, problem-solving, and decision-making skills.
- Leadership and coaching capabilities.
- Ability to prioritize, organize, and meet deadlines in a fast-paced environment.
- Ability to multitask in a fast-paced environment
Job Type
- Full-time
- Remote - United States
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.