Claims Liaison Coordinator

Claims Resolution & Support

• Serve as the primary liaison for complex escalated claim inquiries from providers, members, account management, and internal departments.
• Research and resolve complex claim discrepancies, denials, adjustments, and payment issues within established service-level agreements (SLAs).
• Coordinate with claims examiners, configuration, and payment integrity teams to ensure accurate claim adjudication.
• Document and maintain claim processing instructions and workflows to ensure accurate and efficient processing.
• Provide guidance and mentoring to Claims Liaison Specialists.

• Perform root-cause analysis of claim errors, payment delays, and provider/member complaints.
• Compile and present findings to leadership with recommended solutions.
• Track claim trends and prepare reports on recurring issues, financial impact, and compliance risks.

• Provide clear and timely communication of claim resolutions to providers, members, and internal stakeholders.
• Develop strong working relationships with provider relations, customer service, utilization management, and network management teams.
• Function as a subject‑matter resource on claim workflows and policies.

• Identify opportunities to improve claims workflows, system configuration, and provider/member experience.
• Participate in cross‑functional work groups to implement corrective actions and process enhancements.
• Ensure adherence to state, federal, and accreditation guidelines (e.g., CMS, HIPAA, NCQA).

Performs all other miscellaneous responsibilities and duties as assigned or directed.

#LI-Hybrid

• Associates degree and three years of related work experience; or equivalent combination of education and related work experience.
• Effective written and verbal communication skill, including the ability to communicate and present complex issues in a concise and easy to understand manner.
• Knowledge of process improvement methodologies.
• Knowledge of methodologies for driving increased operational quality.
• Intermediate knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.