Senior Claim Benefit Specialist

Role Overview

• Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines
• Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues
• Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience
• Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise
• Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication
• Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures
• Identifies and reports potential overpayments, underpayments, and other claim irregularities
• Performs claim rework calculations as needed
• Trains and mentors as needed to enhance team performance and technical proficiency
• Conducts outbound calls to obtain required information for claims or reconsideration requests

Requirements

• Minimum of 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
• Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail
• Self-Funding experience preferred
• DG system knowledge preferred
• High School Diploma required
• Preferred Associates degree or equivalent work experience

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources