Claims Resolution Specialist

Albuquerque NM 87113

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 ensurethat 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.

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


Work Experience

Bilingual, Claims, Customer Service


GED (Required), High School (Required)

License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements


Preferred Qualifications:

Education: BA in Psychology, social services, health administration, or business.

Experience: Experience in a Customer Service/Call Center/Health Care/Claims Processing environment.

Minimum Requirements

Education: HS/GED.

Experience: 1-3 years Customer Service.

Computer Skills: Must be a proficient typist, knowledgeable of MS Excel and able to maneuver through various other computer applications, claims and eligibility platforms while verifying demographic information on all calls.

Other: Excellent verbal and written communication skills.Organizational and multi-tasking skills are required.Must demonstrate professional call handling skills while under stress.Must be flexible in scheduling and have the ability to accept change.

Service Delivery Expectations: 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.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.