Claim Benefit Specialist

This is a fully remote position, open to applicants in Alabama, +45 more states.

📋 Description

• Manage and process Benefits claims submitted by healthcare providers.

• Evaluate eligibility and coverage in accordance with insurance plans and policy guidelines.

• Review claims for precision, coding compliance, medical necessity, and documentation requirements.

• Record claim details, codes, modifiers, and other relevant data in company systems.

• Conduct reviews and investigations that necessitate additional scrutiny or validation.

• Liaise with healthcare providers, patients, and stakeholders to resolve discrepancies.

• Ensure that claims processing adheres to regulatory requirements, industry standards, and company policies.

• Provide constructive feedback and take part in performance review processes.

• Analyze claims data and create reports that highlight trends and areas for improvement.

• Review and adjudicate claims in line with processing guidelines.

• Apply medical necessity criteria, confirm eligibility, identify discrepancies, and implement cost containment measures.

• Review claim or referral submissions and execute coding and member/provider identification processes.

• Analyze and process rework claims that cannot be auto-adjudicated.

• Manage route lists and queues in accordance with operational guidelines.

• Utilize relevant system functions to guarantee precise and timely claim processing.

⛳️ Requirements

• 1–2 years of experience in Customer Service.

• Strong collaboration and organizational abilities.

• Excellent and effective communication skills.

• Capability to manage multiple assignments efficiently through effective time management.

• High School diploma, GED, or equivalent experience.

• Experience in a production environment is preferred.

• Prior healthcare experience is preferred.

• Familiarity with utilizing multiple systems simultaneously to resolve complex issues is preferred.

• Claim processing experience is preferred, but not mandatory.

• Understanding of medical terminology is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being, based on eligibility.

• Virtual training for 12–20 weeks.

• Flexible schedule available after successful ramp-up.