Senior Claim Benefit Specialist - Remote
About The Position
Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. Serves as a subject matter expert by coaching colleagues and providing guidance on escalated or technically challenging issues. Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. The role reviews claims that exceed specialist adjudication authority or processing expertise; applies medical necessity guidelines; determines coverage and verifies eligibility; identifies discrepancies; and uses cost-containment measures to support accurate adjudication. It also ensures regulatory compliance and alignment of payments with company policies and procedures, identifies claim irregularities, performs rework calculations, mentors and trains colleagues, and makes outbound calls to obtain information for claims or reconsideration requests.
Requirements
- At least 18 months of medical claim processing experience with a health insurance payor or third-party administrator.
- Proven success working in a high-volume, production-driven environment.
- Ability to manage multiple assignments accurately and efficiently with attention to detail.
- High school diploma.
Nice To Haves
- Self-Funding experience.
- DG system knowledge.
- Associate degree or equivalent work experience.
Responsibilities
- Review pre-specified claims and claims that exceed specialist adjudication authority or processing expertise.
- Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and implement cost-containment measures to support accurate claim adjudication.
- Ensure compliance with regulatory requirements and confirm payments align with company policies and procedures.
- Identify and report potential overpayments, underpayments, and other claim irregularities.
- Perform claim rework calculations as needed.
- Train and mentor colleagues as needed to enhance team performance and technical proficiency.
- Conduct outbound calls to obtain required information for claims or reconsideration requests.
- Address customer service inquiries and resolve issues to support a positive member experience.
- Provide coaching and guidance on escalated or technically challenging issues.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
