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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,