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Medical Claims Advocate - Health Insurance Plans (HMO / PPO) - Alight Solutions (Lincolnshire, IL OR The Woodlands, TX)

Medical Claims Advocate - Health Insurance Plans (HMO / PPO) - Alight Solutions (Lincolnshire, IL OR The Woodlands, TX)

Requisition ID 
Job Locations 
Job Family 
Benefits Service Delivery


Opportunities available in Lincolnshire, IL OR The Woodlands, TX



A critical part of your role as an Advocate will be offering your healthcare benefit expertise with compassion, empathy and sensitivity to assist our customers in resolving their complex healthcare issues. You will be responsible for answering inbound calls from our customers and listening intently to their situation to be sure you gather the necessary information needed to obtain an accurate resolution. Timely interactions with our customers, insurance carriers and healthcare providers throughout the entirety of the issue are also critical to help build confident relationships with our customers and obtain a quicker resolution. These interactions will be conducted via a recorded telephone line or secure email and each interaction will be documented in our case management tool for tracking and record keeping purposes.

Detailed Responsibilities

  • Handle incoming complex calls offering compassion and empathy while using exceptional listening skills to identify the customer’s needs.
  • Resolve customer needs or concerns related to:
    • identification of in-network providers or physician specialists
    • delay or denial of treatment
    • claimsprocessed or denied incorrectly
    • clarification and education on general or specific benefit plans or programs
    • resolution of prescription / drug access or cost issues
    • coordinate access to clinical support for education regarding a diagnosis or treatment plan
  • Full accountability for research and resolution of the customer’s issue including bring in additional resources and communicating final resolution.
  • Review specific employer plan provisions pertinent to resolving customer questions or concerns
  • Investigate identified issue by interacting with the health plan, provider, and other third parties as needed.
  • Refer customers to employer programs and available tools
  • Make outbound/follow-up calls, to provide resolution, to the issue by sharing requested information, educating the customer on how a benefit ‘works’ or referring them to a program for additional support.
  • Document all research and summarize calls in the case management system
  • Become a resource and/or subject matter expert for your aligned employers
  • Provide monthly updates to the client manager with client trends or value-adding suggestions.


Competencies, Knowledge & Experience

Education & Certification

3 years relevant experience in health plan benefits


2 year degree in a health care benefit related field


Work Experience

  • Detailed knowledge of health benefits; PPO plans, High deductible, HSA, HRA
  • Understanding of specific plan coverages and exclusions in medical, prescription, dental, vision, and behavioral health/substance abuse
  • Preferred
    • Medical claim handling, processing and billing
    • Medicare A, B, C, D provisions
    • COBRA
    • Experience with desktop/Windows navigation and keyboarding skills.


  • Exceptional listening skills
  • Excellent customer service expertise and call handling
  • Problem solving and analytical skills
  • Strong organizational and time management proficiencies
  • Flexible and adaptable with a demonstrated ability to recognize the need to change priorities to meet the business needs.
  • Ability to work independently while providing support in a team environment


Work Conditions  

  • Frequent computer use at a workstation for extended periods of time.
  • Access information using a computer and related components and peripherals.
  • Participate in training sessions and meetings.
  • Ability to be flexible with various shifts and possible overtime when business needs require.

We offer you


A competitive total rewards package, continuing education & training, and tremendous potential with a growing worldwide organization.


Our Colleague Experience


At Alight Solutions, we are reimaging how people and organizations thrive. To deliver on this purpose, we do things differently. From company leaders to our newest colleagues, we all play a role in bringing our values to life. Every colleague shapes how Alight can become better, stronger and brighter – together. With technology as our catalyst and humanity at our core, we advance each day toward a better future in work and life.


About Alight Solutions

As the leading provider of benefits administration and cloud-based HR and financial solutions, we enhance work and life through our service, technology and data. Our 22,000 colleagues across 14 global centers deliver an unrivaled consumer experience for our clients and their people. We are Alight. Reimagining how people and organizations thrive.

Alight Solutions provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, sex, sexual orientation, gender identity, national origin, age, disability, veteran, marital, or domestic partner status.  Alight Solutions is committed to a diverse workforce and is an affirmative action employer.


Nothing in this job description restricts management's right to assign or reassign duties and responsibilities of this job to other entities; including but limited to subsidiaries, partners, or purchasers of Aon business units.  



** SEARCH WORDS: Senior Claims Specialist - Claims Examiner - Appeals & Grievance Specialist - Appeals Reviewer - Audit & Appeals Specialist - Billing & Insurance Specialist - Investigative Claims Analyst - Medical Billing - Coding Manager – Medical Biller – Medical Claims Processor **

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