Claims Operations Specialist

Everlywell is a digital health company pioneering the next generation of biomarker intelligence—combining AI-powered technology with human insight to deliver personalized, actionable health answers. We transform complex biomarker data into life-changing insights—seamlessly integrating advanced diagnostics, virtual care, and patient engagement to reshape how and where health happens.

Over the past decade, Everlywell has delivered close to 1 billion personalized health insights, transforming care for 60 million people and powering hundreds of enterprise partners. In 2024 alone, an estimated 1 in 86 U.S. households received an Everlywell test, solidifying our spot as the #1 at-home testing brand in the country. And we’re just getting started. Fueled by AI and built for scale, we’re breaking down barriers, closing care gaps, and unlocking a more connected healthcare experience that is smarter, faster, and more personalized.

The Claims Operations Specialist supports the day-to-day activities of the revenue cycle and payer operations team within Everlywell. This role is responsible for accurate and timely claims management, payer communication, and follow-up on outstanding accounts. The position also assists with payer enrollment, maintains operational documentation, and provides support for chart review related to HEDIS and risk adjustment. In addition, this role may participate in cross-functional projects and provide administrative support across the enterprise as needed. The specialist works closely with internal teams and payer partners and must be comfortable navigating EHR systems, including Athena.

Claims Management and Follow-Up::
• Review insurance claims daily to verify accuracy, completeness, and compliance with billing requirements.
• Follow up on outstanding accounts receivable, including unpaid, underpaid, and denied claims across all payer types.
• Identify recurring denial or claim-related issues and collaborate with internal teams to recommend and implement process improvements.
• Enter and maintain claim-related data in the EHR, including completing manual claims when needed

Reporting, Analysis, and Operational Documentation::
• Monitor and report claims activity, including preparing dashboards and reports to support KPI tracking.
• Load allowable schedules and other billing data into the EHR to support operational accuracy.
• Develop, update, and maintain standard operating procedures, process guides, workflows, and other operational documentation.

Payer Enrollment and Payer Relationship Support :
• Support payer enrollment by preparing required applications, tracking progress, and coordinating with payer representatives.
• Assist with new payer setup within internal systems, including verification of requirements and configuration updates.
• Maintain accurate records related to payer enrollment and credentialing activities.

Quality Review and Cross-Functional Support :
• Assist with chart review for HEDIS, risk adjustment, and other quality or compliance-related initiatives as assigned.
• Participate in cross-functional projects that support enterprise-wide goals, including administrative tasks and operational support.
• Collaborate with internal teams across the organization to ensure timely completion of assigned tasks and consistent communication.

Required Knowledge, Skills, and Abilities::
• Solid understanding of medical billing processes, including CPT/ICD coding basics and the full claims lifecycle.
• Familiarity with payer rules, reimbursement practices, and denial management.
• Proficiency with EMR/EHR systems; experience with Athena is a plus.
• Strong organizational skills with the ability to manage multiple tasks and deadlines.
• Clear and professional communication skills.
• High degree of accountability and initiative.
• Ability to recognize issues, interpret trends, and recommend improvements.
• Strong attention to detail and accuracy.

Education and Experience Requirements:
• High school diploma or equivalent required; bachelor’s degree preferred.
• At least 5 years of experience in medical billing, revenue cycle operations, or a related healthcare administrative role.
• Experience working directly with payers on claim follow-up and denial resolution.
• Experience with Athena or another EMR/EHR platform required.