Senior Claim Benefit Specialist

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

📋 Description

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

• Offer subject matter expertise, coaching, and support for escalated or technically challenging matters.

• Assist customer service operations by responding to inquiries and resolving issues effectively.

• Review predetermined claims and those that exceed the authority or expertise for specialist adjudication.

• Implement medical necessity guidelines, assess coverage, confirm eligibility, pinpoint discrepancies, and execute cost-containment strategies.

• Ensure adherence to regulatory requirements and verify that payments comply with company policies and procedures.

• Detect and report potential overpayments, underpayments, and other irregularities in claims.

• Carry out claim rework calculations.

• Provide training and mentorship to team members as necessary.

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

⛳️ Requirements

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

• Proven track record of success in a high-volume, production-oriented environment.

• Ability to handle multiple assignments with precision, efficiency, and attention to detail.

• High School Diploma is mandatory.

• 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