Specialist Benefit Review

DELTA HEALTH SYSTEMS MCC•Stockton, CA

2d•$24 - $24•Onsite

About The Position

The Delta Health Systems Benefit Review Specialist researches complaints, appeals, and grievances from plan participants and providers. The specialist applies plan contract language, benefits, and covered-service provisions to determine accurate resolutions in accordance with self-funding plan documents, NAIC regulations, and CMS guidelines. The role also involves system configuration in collaboration with Plan Build Benefits to ensure claims are processed according to plan provisions. The specialist handles phone inquiries and explains benefits, policies, procedures, claim processing, plan documents, and denial logic to participants, providers, and internal departments. The specialist reviews claims and appeals, researches coding and benefit issues, evaluates medical notes and plan documents, and documents determinations. The role includes coordinating reviews with HCI, preparing acknowledgment and resolution letters, requesting information, and ensuring that claim documentation is imaged and recorded appropriately. The specialist collaborates across departments on configuration and medical-policy requirements, performs department metrics, and carries out other duties as required.

Requirements

Strong understanding of AMA, CPT, CDT, HCPCS, Revenue, and ICD-10 coding structures for medical and dental claims, including how codes relate to benefit application.
Knowledge of Coordination of Benefits (COB).
Knowledge of Third-Party Liability (TPL).
Ability to interpret medical and dental terminology.
Ability to read and interpret dental X-rays, periodontal charts, and narrative reports.
Ability to read, understand, and interpret client summary plan documents, NAIC regulations and guidelines, CMS guidelines, and network medical policies.
Ability to review industry standards and Healthcare Reform and determine whether plan benefits differ.
Understanding of Usual and Customary concepts, network pricing, claim calculation, and validation.
Ability to understand technical issues and demonstrate strong comprehension skills.
Advanced computer skills, particularly in Word and Excel, and basic knowledge of database applications.
Strong written and verbal communication skills.
Good organizational skills and the ability to manage time and resources effectively and work well under pressure.
Ability to work independently.

Responsibilities

Research participant and provider complaints, appeals, and grievances and determine accurate resolutions using plan documents, regulations, guidelines, and applicable policies.
Apply contract language, benefits, and covered-service provisions when reviewing claims and appeals.
Collaborate with Plan Build Benefits and other internal departments on system configuration to ensure claims processing follows plan provisions and medical-policy guidelines.
Handle phone inquiries from plan participants, providers, and internal departments.
Interpret and explain plan benefits, policies, procedures, functions, claim processing, plan documents, and denial logic.
Log received appeals in Excel and document claim notes and final determinations for processor handling.
Review work in order of receipt and assess complaint validity; review medical notes and plan documents to determine appeal outcomes.
Scan and send supporting documentation to HCI for review of edited codes, receive HCI determinations, and respond by letter or process claim adjustments.
Write letters requesting information or explanations of payment issues, and prepare accurate acknowledgment and resolution letters.
Ensure all claim documentation is imaged and documented appropriately.
Research difficult appeals using online sources, plan documents, coding manuals, and external resources to determine accurate claim processing.
Perform standard department metrics against established goals and objectives.
Review claims and appeals in a timely manner and remain professional with internal and external customers.
Perform other duties as required.