Claim Benefit Specialist – Commercial Operations

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

📋 Description

• Manage and process benefit claims submitted by healthcare providers.

• Assess eligibility for benefits and coverage based on insurance policies and guidelines.

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

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

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

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

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

• Create and implement feedback mechanisms and formal performance review processes.

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

• Review and adjudicate claims in accordance with processing guidelines.

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

• Review claim or referral submissions while applying coding, member identification, and provider selection processes.

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

• Manage routing lists and queues in line with operational guidelines.

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

⛳️ Requirements

• 1–2 years of experience in Customer Service.

• Strong teamwork and organizational capabilities.

• Excellent communication skills.

• Ability to manage multiple tasks effectively through time management.

• Capability to work accurately and efficiently.

• 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.

• High School diploma, GED, or equivalent experience.

🏝️ 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.