Claim Benefit Specialist – Commercial Operations

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

📋 Description

• Manage and process Benefits claims received from healthcare providers

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

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

• Record claim details, including codes, modifiers, and other data points in company systems

• Perform reviews and investigations that require additional scrutiny or validation

• Liaise with healthcare providers, patients, and stakeholders to address discrepancies

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

• Offer feedback and engage in formal performance evaluations to enhance service delivery and team development

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

• Review and adjudicate claims following established processing guidelines

• Implement medical necessity guidelines, confirm eligibility, detect discrepancies, and execute cost containment strategies

• Examine claims or referrals and apply coding, member identification, provider selection, and pre-coding processes

• Analyze and process rework claims that cannot be automatically adjudicated

• Manage route lists and queues as per operational guidelines

• Utilize applicable system functions to guarantee accurate and timely claim processing

• Complete 12–20 weeks of virtual training from 8:00 AM to 4:30 PM EST

⛳️ Requirements

• 1–2 years of experience in Customer Service

• Strong teamwork and organizational capabilities

• Excellent and effective communication skills

• Ability to manage multiple tasks competently through effective time management, accurately and efficiently

• High School diploma, GED, or equivalent experience

• Experience in a production environment (preferred)

• Background in healthcare (preferred)

• Familiarity with using multiple systems concurrently to address complex issues (preferred)

• Claim processing experience (preferred but not mandatory)

• Knowledge of medical terminology (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 following successful ramp-up