Claim Benefit Specialist – Commercial Operations

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Manages and processes Benefits claims submitted by healthcare providers, ensuring precision, efficiency, and compliance with policies and guidelines.

• Evaluates eligibility and coverage of benefits according to insurance plans and policy regulations.

• Reviews claims for accuracy, coding compliance, medical necessity, and documentation criteria.

• Records claim details, codes, modifiers, and data elements in company systems.

• Undertakes reviews and investigations that require additional scrutiny or validation.

• Engages with healthcare providers, patients, and stakeholders to resolve discrepancies in claims.

• Ensures claims processing aligns with regulatory standards, industry norms, and company policies.

• Reviews and adjudicates claims according to established processing guidelines.

• Implements medical necessity guidelines, verifies eligibility, identifies discrepancies, and applies cost containment strategies.

• Evaluates claims or referral submissions and applies coding, member identification, provider selection, and pre-coding requirements.

• Analyzes and processes rework claims that cannot be auto-adjudicated.

• Manages route lists and queues in accordance with operational procedures.

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

• Analyzes claims data and produces reports to identify trends and areas for improvement.

• Develops and implements feedback and formal performance review processes to enhance service delivery, engagement, motivation, and team development.

⛳️ Requirements

• 1-2 years of experience in Customer Service.

• Demonstrates strong teamwork and organizational abilities.

• Possesses strong and effective communication skills.

• Capable of managing multiple assignments efficiently through effective time management.

• High School diploma, GED, or equivalent experience.

• Experience in a production environment is preferred.

• 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.