Senior Claims Benefit Specialist

Role Overview

• Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims
• Adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines
• Process provider refunds and returned checks
• Handle customer service inquiries and problems
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
• Perform claim re-work calculations
• Follow through completion of claim overpayments, underpayments, and any other irregularities
• Process complex non-routine Provider Refunds and Returned Checks
• Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals
• Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures
• Review and handle relevant correspondences assigned to the team that may result in adjustment to claims
• May provide job shadowing to lesser experience staff

Requirements

• 2+ years medical claim processing experience
• Experience in a production environment
• Effective communications, organizational, and interpersonal skills
• DG system claims processing experience preferred
• Associate degree preferred
• High School Diploma or GED required

Benefits

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• comprehensive benefits package