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.
• 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
• DG system knowledge
• 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
• other resources, based on eligibility