Healthcare Insurance Operations Specialist

Compensation:

Philippines: DOE and flexible for exceptional hire

Location: Remote, Philippines or South Africa
Employment Type: Full-Time Independent Contractor
Schedule: U.S. business-hours overlap required

About the Company

Our client is a venture-backed technology company building a modern banking platform specifically for the healthcare industry.

The company is developing technology to support complex financial and insurance workflows within healthcare, including claims processing, payer interactions, eligibility verification, and insurance operations.

As the company builds this function, it is taking a quality-over-volume approach. Rather than building a large BPO-style team, the company is looking for exceptional insurance operations professionals who bring deep hands-on expertise, strong judgment, and a process-improvement mindset.

The Opportunity

This is an opportunity for an experienced healthcare insurance operations professional to become an early, foundational member of the team.

The successful candidate will work directly with U.S. healthcare payers and manage the operational work required to move claims and insurance processes forward. This includes payer follow-up, eligibility and benefits verification, claims research, and resolving issues that prevent claims from progressing.

The ideal candidate will be experienced enough to operate independently while also recognizing opportunities to improve and automate repetitive workflows as the company scales.

This is not a high-volume, script-driven call center position. The company is looking for someone who understands the underlying insurance processes and can investigate problems, communicate effectively with payers, and exercise sound judgment.

Key Responsibilities

Claims & Payer Operations

Follow up directly with U.S. insurance payers regarding outstanding, pending, denied, or otherwise unresolved claims.
Contact payers by phone and through payer portals to obtain claim status, payment information, denial reasons, and required next steps.
Research claims and determine why they are delayed, denied, or otherwise unable to move forward.
Escalate and resolve issues with payers when appropriate.
Maintain accurate documentation of payer interactions, claim status, and resolution steps.

Eligibility & Benefits Verification

Perform detailed eligibility and benefits verification with U.S. health insurance payers.
Confirm coverage, effective dates, benefits, and other relevant insurance information.
Conduct payer outreach when information cannot be confirmed through electronic systems or portals.
Identify discrepancies or missing information and determine the appropriate next step.

Insurance Operations & Process Improvement

Work independently across a range of healthcare insurance and claims-related workflows.
Identify recurring issues, bottlenecks, and manual processes within day-to-day operations.
Document workflows and recommend ways to make processes more efficient, consistent, and scalable.
Help identify opportunities where repetitive insurance operations could eventually be supported through technology or automation.
Provide practical insight to internal product and engineering teams regarding real-world insurance workflows.

Data Accuracy & Compliance

Maintain highly accurate records across internal systems and payer platforms.
Handle sensitive healthcare and patient information responsibly and in accordance with applicable privacy and security requirements.
Follow established HIPAA and PHI-handling procedures.
Ensure documentation and operational data are complete, accurate, and up to date.

What We're Looking For

Required Experience

3+ years of hands-on experience in U.S. healthcare insurance operations, medical billing, revenue cycle management, claims processing, eligibility verification, or a closely related function.
Demonstrated experience communicating directly with U.S. healthcare insurance payers.
Strong understanding of U.S. insurance claims and payer workflows.
Experience with eligibility and benefits verification and claims follow-up.
Experience working with payer portals and healthcare administration systems.
Strong working knowledge of HIPAA and appropriate handling of PHI.
Excellent written and spoken English with the confidence to communicate professionally with U.S. insurance representatives.

Strongly Preferred

Experience working for a U.S. healthcare BPO, digital health company, healthcare technology company, or internal insurance operations team.
Experience with major U.S. commercial payers such as UnitedHealthcare, Aetna, Cigna, or Blue Cross Blue Shield.
Experience working with Medicare and/or Medicaid.
Experience handling claims denials, appeals, or complex payer issues.
Experience in an environment where operational processes were being built, improved, or scaled.

The Ideal Candidate

The ideal candidate is:

Exceptionally detail-oriented and accurate.
Comfortable investigating a problem rather than simply following a script.
Confident speaking with U.S. insurance representatives.
Able to work independently and take ownership of assigned workflows.
Naturally curious about why something is happening, not just what needs to be done.
Comfortable working in a technology-driven environment.
Interested in identifying repetitive manual work that could eventually be improved or automated.
Experienced enough to bring judgment and insight without requiring extensive hand-holding.

Why This Role Matters

This is an opportunity to join an early-stage healthcare technology company at a foundational point in its operations.

The initial focus is on getting the work done exceptionally well. As the business grows, the person in this role will have the opportunity to help shape how these insurance workflows are performed, documented, improved, and ultimately automated.

Healthcare Insurance Operations Specialist - 63564490321