Claim Benefit Specialist – Commercial Operations

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

📋 Description

• Manage and process benefits claims submitted by healthcare providers.

• Assess eligibility for benefits and coverage in accordance with insurance plans and policy guidelines.

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

• Record claim information and assign the correct codes, modifiers, and data elements.

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

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

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

• Deliver regular, timely feedback and engage in formal performance evaluations and team development.

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

• Review and adjudicate claims in line with processing guidelines.

• Implement medical necessity guidelines, verify eligibility, identify inconsistencies, and apply cost containment measures.

• Review referrals and submissions while applying coding, member identification, and provider selection processes.

• Analyze and process rework claims that are not eligible for auto-adjudication.

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

• Utilize relevant system functions to ensure accurate and prompt claim processing.

⛳️ Requirements

• 1–2 years of experience in Customer Service.

• Strong teamwork and organizational capabilities.

• Effective communication skills.

• Ability to manage multiple assignments with competence through time management, accurately and efficiently.

• 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.

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

• Ability to work 40 hours per week.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Virtual training for 12–20 weeks.

• Flexible schedule available after successful ramp-up.