Claims Resolution Specialist

San Diego CA 92108

Job Description

The Claims Resolution Specialist serves as the claims functional expert within the CMC. The specialist uses this expertise to aid others in the CMC in the interpretation of claims payment. When claims issues cannot be resolved by others in the CMC or the amount of time involved in claims problem resolution is anticipated to be excessive, claims issues are escalated to the Resolution Specialist. The Specialist has the responsibility for accurate and timely claims research of all claim types. When a recalculation is warranted and modification to the payment amount is determined to be required, acting within established parameters, the Specialist will make the appropriate payment adjustment in the claims system. When a payment adjustment is outside the scope of the Specialist or the degree of complexity necessitates, the Specialist will coordinate resolution of issues with the Claims Department. The Specialist will ensure that documentation is made in the appropriate system to ensure all pertinent information is recorded both for ease of resolution by the Claims Department and service continuation for the customer. When appropriate, the Resolution Specialist will update members and providers with the disposition of payment. When call volume warrants, this position will also have responsibility of serving calls from members and providers with inquiries as they relate to eligibility, benefits, claims, authorization of services and other Magellan products and services. As the resident claims expert, the Claims Resolution Specialist may be called upon by the Learning and Development Team, Supervisors or others in the CMC to aid in CMC education activities.

Essential Functions

Researches claims status, provider reimbursement check tracing, requests reissuance of Explanation of Benefits ( EOB) , researches and resolves EAP ad hoc claims, makes claims adjustments within established parameters. Maintains research tracking log of claims issues. Maintains claims data entry error and TAT QI report.
Provides back-up and additional support to customer service representatives as warranted by needs of service. Researches and provides information regarding member eligibility, benefits, EAP services, claim status, and authorization inquiries to callers while maintaining confidentiality..
Documents calls and forwards required information to the appropriate staff. Coordinates with Corporate Claims as required.
Serve as CMC claims subject matter expert and assist in education of colleagues.


Essential Functions

Performs various other duties and special projects that are assigned on a daily basis while performing their primary function.


One must be customer service oriented, team player, maintain member and provider confidentiality at all times, demonstrate effective problem solving skills, and be punctual and maintain good attendance.


Sitting, Typing


Education: HS/GED
Experience: 1-3 years
Job Specific: Customer Service
Other: Excellent verbal and written communication skills, organizational skills required and the ability to handle multiple tasks. Must demonstrate professional call handling skills while under stress. Must be flexible in scheduling and have the ability to accept change
Computer Skills: Must be a proficient typist, knowledgeable of MS Excel and able to maneuver through various other computer application claims and eligibility platforms while verifying demographic


Education: BA in Psychology, social services, health administration, business
Experience: Experience in a Customer Service/Call Center/ Health Care/Claims Processing environment

General Job Information


Claims Resolution Specialist



Job Family

Operations Group


United States of America

FLSA Status

United States of America (Non-Exempt)

Recruiting Start Date


Date Requisition Created


Minimum Qualifications



License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements


  • Ability to review and interpret contract/account information to successfully resolve issues regarding claim disputes.
  • Demonstrated ability for problem solving, meeting deadlines, showing initiative and follow-through.
  • Must be a proficient typist. 
  • Working knowledge of Microsoft Office Product Suite, specifically Excel.
  • Ability to simultaneously maneuver through various computer claims and eligibility platforms while verifying information while on the telephone. 
  • Excellent verbal and written communication skills.
  • Must demonstrate professional call handling skills while under stress.
  • Customer service oriented and a team player.
  • Must maintain member and provider confidentiality at all times.
  • Must be flexible in scheduling, be punctual and maintain good attendance.
  • Understanding of customer service performance metrics (ASA, abandonment rate, talk time). 
  • Comfortable adapting to change.
  • Bilingual preferred.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled