Senior Claim Benefit Specialist

This is a fully remote position, open to applicants in Louisiana, +3 more states.

📋 Description

• Evaluates and adjudicates intricate, sensitive, and specialized medical claims in line with established processing guidelines.

• Acts as a subject matter authority by offering coaching and guidance on escalated or technically complex issues.

• Aids customer service operations by addressing inquiries and resolving issues to promote a positive experience for members.

• Reviews pre-defined claims and those that surpass specialist adjudication authority or processing expertise.

• Utilizes medical necessity guidelines to determine coverage, verify eligibility, identify discrepancies, and implement cost-containment strategies to ensure precise claim adjudication.

• Guarantees compliance with all regulatory mandates and verifies that payments adhere to company policies and procedures.

• Detects and reports potential overpayments, underpayments, and other irregularities in claims.

• Performs recalculations of claims as required.

• Provides training and mentorship as necessary to improve team performance and technical skills.

• Makes outbound calls to gather necessary information for claims or reconsideration requests.

⛳️ Requirements

• A minimum of 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.

• Demonstrated capability to manage multiple tasks with precision, efficiency, and attention to detail.

• Experience with self-funding is preferred.

• Knowledge of the DG system is preferred.

• High School Diploma is required.

• An Associate's degree or equivalent work experience is preferred.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off.

• Retirement savings options.

• Wellness programs and additional resources.