Senior Claim Benefit Specialist

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

📋 Description

• Review and adjudicate intricate, sensitive, and specialized medical claims in accordance with established plan processing guidelines.

• Act as a subject matter expert by offering coaching and guidance on escalated or technically challenging matters.

• Assist customer service operations by addressing inquiries and resolving issues.

• Examine pre-specified claims and those exceeding the specialist's adjudication authority or processing expertise.

• Implement medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and execute cost-containment strategies.

• Ensure compliance with regulations and verify that payments are consistent with company policies and procedures.

• Detect and report potential overpayments, underpayments, and other claim irregularities.

• Conduct claim rework calculations.

• Provide training and mentorship as needed.

• Make outbound calls to gather required information for claims or reconsideration requests.

⛳️ Requirements

• At least 18 months of experience in medical claim processing with a health insurance payer or third-party administrator.

• Proven track record of success in a high-volume, production-driven setting.

• Demonstrated capability to handle multiple assignments with accuracy, efficiency, and meticulous attention to detail.

• High School Diploma is a mandatory requirement.

• Experience with Self-Funding is preferred.

• Familiarity with the DG system is preferred.

• An Associate's degree or equivalent work experience 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, based on eligibility.