Claims Technical Review Specialist

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

📋 Description

• Conducts comprehensive technical evaluations of various claims in alignment with Company protocols.

• Undertakes technical assessments and analyses of all claim types to ensure accuracy and compliance with established procedures and plan standards.

• Manages appeals through thorough research and documentation; prepares denial or approval correspondence.

• Oversees predetermination assessments and analyzes to ascertain benefit allowances and categories.

• Handles refunds, voids, and overpayments, including necessary claim adjustments.

• Processes time loss claims while liaising with local union offices, medical service providers, employers, and members.

• Reviews and interprets new benefit plans or modifications to existing plans.

⛳️ Requirements

• High School Diploma or GED is mandatory.

• Minimum of three years' experience in processing various types of group health benefit claims.

• Comprehensive understanding of all facets of benefits claims processing and adjudication principles and practices.

• Proficient knowledge of terminology associated with medical and dental claims processing, including HCFA, CPT-4, ICD-10, and HCPCS.

• Experience in interpreting Plan documents and/or certificates of coverage related to benefits, eligibility, exclusions, and limitations.

• Capability to perform calculations involving discounts, interest, proportions, and percentages.

• Strong familiarity with Claims systems.

• Proficient computer skills, including MS Office Tools and Applications.

🏝️ Benefits

• Health insurance

• Vision coverage

• Dental coverage

• 401(k) plan with company match

• Paid time off (PTO)

• Opportunities for growth