Specialist Benefit Review

DELTA HEALTH SYSTEMS MCC•Stockton, CA

2d•$24 - $24

About The Position

The Delta Health Systems Benefit Review Specialist researches Plan Participant and Provider complaints, appeals, and grievances. The specialist applies contract language, benefits, and covered services to determine accurate resolutions in accordance with Self-Funding Plan Documents, NAIC Regulations, and CMS Guidelines. The role also collaborates with Plan Build Benefits on system configuration to ensure claims processing follows plan provisions, and handles phone inquiries from Plan Participants, Providers, and internal departments. The position requires interpreting medical and dental terminology and coding, plan documents, regulations, guidelines, network medical policies, and healthcare reform requirements. The specialist reviews claims and appeals, determines validity and outcomes, documents findings, prepares correspondence, supports claim adjustments, and explains claim processing and benefit decisions to customers and colleagues. The role also performs department metrics, maintains claim documentation, and collaborates with internal departments to align system configuration with medical policy guidelines and plan provisions.

Requirements

Strong understanding of American Medical Association (AMA), CPT, CDT, HCPCS, Revenue, and ICD10 coding for medical and dental claims.
Knowledge of Coordination of Benefits (COB).
Knowledge of Third-Party Liability (TPL).
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 work well under pressure.
Ability to interpret medical and dental terminology and coding structures and understand how codes relate to benefit application.
Ability to read, understand, and interpret Client Summary Plan Documents, NAIC Regulations and Guidelines, CMS Guidelines, and Network Medical Policies.
Ability to interpret dental X-rays, periodontal charts, and narrative reports.
Ability to work independently and manage time and resources effectively.
Strong comprehension skills and ability to understand technical issues.
Ability to interpret and explain plan benefits, policies, procedures, and functions to participants and internal and external customers.

Responsibilities

Research complaints, appeals, and grievances from Plan Participants and Providers and determine accurate resolutions based on plan documents, regulations, and guidelines.
Apply contract language, benefits, and covered services when reviewing claims and appeals.
Configure systems in collaboration with Plan Build Benefits to support plan provisions and appropriate claims processing.
Handle phone inquiries from Plan Participants, Providers, and internal departments.
Interpret medical and dental terminology, coding, dental X-rays, periodontal charts, and narrative reports.
Review plan documents, medical notes, network medical policies, industry standards, and healthcare reform requirements to determine benefit application and appeal outcomes.
Understand and apply usual and customary concepts, network pricing, claim calculations, and validation.
Perform standard department metrics against established goals and objectives.
Log appeals in Excel and document claim notes and final determinations for processor handling.
Organize work in order of receipt and review complaints for validity.
Scan and send supporting documentation to HCI for review of edited codes; receive determinations and respond by letter or process claim adjustments.
Write letters requesting information or explaining payment issues, and create accurate acknowledgment and resolution letters.
Ensure claim documentation is imaged and documented appropriately.
Answer questions from customer service and processors about claim processing, plan documents, and denial logic.
Research difficult appeals using online sources, plan documents, coding manuals, and external resources.
Review claims and appeals in a timely manner.
Maintain professionalism with internal and external customers.
Collaborate with internal departments to ensure system configuration meets medical policy guidelines and plan provisions.
Perform other duties as required.