Healthcare Support Representative

XO Health believes healthcare is fixable. Become part of the community changing the face of the industry. XO Health is the first health plan designed by and for self-insured employers that delivers a more unified health experience for everyone – from those who receive care, to those who deliver it, to those who pay for it. We are growing a multi-disciplinary team of diverse and digitally empowered employees ready to rebuild trust in healthcare through comprehensive and unified transformation. XO Health Healthcare Support Representative About the job XO Health believes healthcare is fixable. Become a part of the community changing the face of the industry. XO Health is the first health plan designed by and for self-insured employers that delivers a more unified health experience for everyone-from those who received care, to those who deliver it, to those who pay for it. We are growing a multi-disciplinary team of diverse and digitally empowered employees ready to rebuild trust in healthcare through comprehensive and unified transformation. About the Role: Remote- USA, India -Virtual Contact Center and Claims Operations The Operations Specialist is a key member of XO Health’s operations team, supporting both member/provider service (Advocacy) and claims processing and resolution (Claims Operations). This blended role serves as a primary point of contact for members and providers through an omni-channel environment (phone, email, chat), while also functioning as a claim’s operations expert responsible for accurate claim processing, research, adjudication, adjustments, and issue resolution. This position requires a strong service-first mindset, high attention to detail, and the ability to move seamlessly between real-time support and behind-the-scenes operational work. The Operations Specialist partners cross-functionally with internal teams and third-party vendors to ensure members and providers receive timely, compliant, and high-quality support across the operations. Key Responsibilities: Member & Provider Advocacy Handle inbound and outbound member and provider inquiries via phone, email, and chat with professionalism and empathy. Initiative member outreach to provide information and assistance regarding benefits. Provide accurate information regarding benefits, eligibility, and coverage; claims status and adjudication details; prior authorization requirements and submissions; billing and reimbursement policy questions; and provider portal navigation and support. Resolve inquiries, complaints, grievances, and escalations promptly while ensuring complete documentation and proper routing when needed. Conduct follow-up outreach to ensure resolution, satisfaction, and continuity of care or claim outcomes. Build trust with members and providers through early, frequent, and personalized engagement. Claims Processing, Adjudication & Resolution Process, research, and adjudicate institutional and professional medical claims (including behavioral health), ensuring accuracy, timeliness, and compliance. Verify eligibility, coverage, and medical necessity under policy guidelines using established systems and workflows. Investigate and resolve claim denials, appeals, discrepancies, overpayments, and billing errors and payment issues. Conduct overpayment reviews, coordinate recovery actions, and correct claim financial histories as required. Support high-cost claim and claimant processes as needed. Provider Data, Outreach & Operational Support Perform provider outreach as necessary to support claims resolution, documentation needs, and payment accuracy. Collect W-9s and maintain accurate provider information within XO systems to support claims processing, reporting, directory publication, and data transfers. Cross-Functional Collaboration & Continuous Improvement Collaborate with Business Operations, Network Performance, Product, and Experience teams to resolve complex cases and improve service delivery. Coordinate with third-party claims vendors to maintain accuracy, compliance, and service excellence. Identify recurring issues, system gaps, or process inefficiencies and provide feedback to leadership. Perform quality assurance reviews to ensure claims financial and procedural accuracy. Document procedures, workflows, and operational guidance as needed. Performance & Compliance Expectations Meet performance goals in areas such as efficiency and productivity, quality and accuracy, customer satisfaction, compliance, follow-up completion, and attendance. Maintain confidentiality and compliance with HIPAA, ERISA, and XO Health policies. Experience Required: The qualified candidate will have: 3–5 years of experience in a healthcare payer, TPA, or health insurance environment, with a blend of contact center/member-provider support and/or medical claims processing/adjudication/claims operations. Strong knowledge of health insurance concepts, benefits and eligibility, medical terminology, and claims lifecycle management. Strong English language verbal and written communication skills, with an empathetic, solution-oriented approach. High attention to detail, sound judgment, and strong analytical problem-solving skills. Ability to multitask in a fast-paced, digital-first environment while maintaining accuracy and professionalism. Proficiency in Microsoft Office Suite and customer service and/or claims processing systems. Preferred Skills: Associate or bachelor’s degree in healthcare administration, business, or a related field. Experience with consolidated billing/payment platforms and/or alternative payment models (bundled payments). Familiarity with Availity Essentials, payer portals, and EDI standards. Familiarity with Genesys, Service Now, and other CRM tools Familiarity with Facility, DME, Behavioral Health, and Stop-Loss claim types. Experience in payment integrity, provider relations, or medical billing. Spanish language proficiency (written and verbal) is a plus. Additional Details: Must be able to support USA contact center hours. Must be able to participate in a rotating on-call schedule for urgent member and provider support needs. Full compensation packages are based on candidate experience and relevant certifications. ₹500,000 — ₹1,500,000 INR XO Health is an equal opportunity employer committed to diversity and inclusion in the workplace. All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth or related medical conditions), race, color, age, national origin, religion, disability, genetic information, marital status, sexual orientation, gender identity, gender reassignment, citizenship, immigration status, protected veteran status, or any other basis prohibited under applicable federal, state or local law. XO Health promotes a drug-free workplace.