Bilingual Claims Service Representative

Our customer specializes in insurance claims processing and they are growing here in Tampa Bay. The Bilingual Claims Service Representative is responsible for providing exceptional service to members, providers, and payers by resolving claims-related inquiries accurately, efficiently, and professionally in both English and Spanish. This role serves as a primary point of contact for questions regarding medical, pharmacy, vision, and related healthcare claims, payments, denials, eligibility impacts, and Explanation of Benefits (EOBs). The representative investigates claim issues, explains claim outcomes, and works collaboratively with internal teams to ensure timely resolution while maintaining compliance with organizational policies and procedures.

Duties and Responsibilities:

• Respond to inbound calls and written inquiries from members, providers, and payers regarding claims status, payments, denials, adjustments, eligibility, benefits, and Explanation of Benefits (EOBs) in English and Spanish.
• Research and resolve claim-related questions, complaints, and concerns by reviewing claim information, benefit plans, payment details, and applicable policies.
• Explain claim adjudication outcomes, payment determinations, denials, and appeal processes to ensure customer understanding.
• Investigate and document claim discrepancies, processing errors, and billing concerns while identifying appropriate resolution pathways.
• Maintain accurate and detailed records of customer interactions, claim reviews, and actions taken within designated systems.
• Process requests for claim reconsiderations, corrections, and escalations according to established procedures.
• Collaborate with internal departments, providers, and payers to resolve complex claims issues and ensure timely follow-up.
• Respond promptly to voicemail messages, correspondence, and customer requests requiring additional research.
• Utilize claims systems, policy guidelines, and reference materials to make informed decisions and provide accurate information.
• Strive for first-call resolution by demonstrating strong claims knowledge, critical thinking, and problem-solving skills.
• Meet or exceed departmental performance metrics, including quality, productivity, accuracy, service levels, and customer satisfaction.
• Identify trends and recurring claim issues and communicate findings to leadership as appropriate.
• Escalate complex or unresolved claims issues in accordance with departmental procedures.

Experience & Education Requirements:

• High School Diploma or equivalent required.
• Bilingual proficiency in English and Spanish required (including speaking, reading, and writing.)
• Minimum one (1) year of experience in healthcare claims, health insurance customer service, claims administration, medical billing, or a related healthcare environment.
• Working knowledge of healthcare claims processing, claim adjudication, EOB, billing practices, denials, provider reimbursements, and medical terminology.
• Ability to review, interpret, and explain claim details, payment information, and benefit determinations to members and providers.
• Proficiency with Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint.
• Excellent verbal and written communication skills with the ability to communicate professionally and effectively with internal and external customers.
• Strong analytical and problem-solving abilities, including researching claim issues and identifying appropriate resolutions.
• Demonstrated attention to detail and accuracy when reviewing claims, documenting interactions, and completing assignments.
• Ability to maintain confidentiality and handle sensitive healthcare information appropriately.
• Ability to make sound decisions using available resources, policies, and established guidelines.
• Demonstrated commitment to quality, continuous improvement, and customer satisfaction.
• Ability to build trust and maintain professional relationships with customers, providers, coworkers, and leadership.
• Ability to work overtime as business needs require.

Pay: $50,000 to $55,000 annually

Hours: flexibility between 8am to 8pm, Monday to Friday

Location: Onsite in Tampa - 33634

Benefits to include medical, dental, vision, 401(k) with a match, PTO, paid holidays, and more!

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.