Claim Benefit Specialist

This is a fully remote position, open to applicants in Alabama, +43 more states.

📋 Description

• Manage and process benefit claims submitted by healthcare providers.

• Evaluate benefit eligibility and coverage according to insurance plans and policy guidelines.

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

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

• Examine and investigate claims that require further scrutiny or validation.

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

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

• Review and adjudicate standard claims following processing guidelines.

• Analyze and approve routine claims that cannot be automatically adjudicated.

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

• Coordinate responses to routine phone inquiries and written correspondence.

• Direct and triage complex claims to the Senior Claim Benefits Specialist.

• Review claim or referral submissions and apply relevant guidelines, coding, member identification, diagnosis, and pre-coding criteria.

• Provide training while serving as a subject matter expert.

• Oversee claims, queues, and ECHS within designated turnaround-time parameters.

• Utilize applicable system functions, including claim checks, reasonable and customary data, and post-containment tools.

• Create and implement feedback and performance review processes.

• Analyze claims data and generate reports to identify trends and areas for improvement.

⛳️ Requirements

• Less than 1 year of work experience.

• Basic knowledge of problem-solving and decision-making skills.

• High school diploma or equivalent is required.

• Experience in a production environment.

• Claims processing experience in any field.

• Preferred: Medicaid experience.

• Preferred: Familiarity with QNXT.

• Preferred: Experience in Medical Coding.

• Preferred: Proficiency in Microsoft Outlook/Excel.

• Ability to commit to a 20-week training schedule.

• Availability to work Monday through Friday, 9 AM–5:30 PM EST (8 AM–4:30 PM CST, 7 AM–3:30 PM MST, 6 AM–2:30 PM PST).

🏝️ 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.