Senior Claims Benefit Specialist

This is a fully remote position, open to applicants in Louisiana, +4 more states.

📋 Description

• Evaluate and modify self-funded, fully insured, Reinsurance, and/or RX claims.

• Process intricate, sensitive, and/or specialized claims in line with established processing guidelines.

• Manage provider refunds and returned checks.

• Address customer service inquiries and resolve issues.

• Execute adjustments of all monetary amounts on customer service platforms, leveraging claims processing expertise.

• Implement medical necessity criteria, assess coverage, and finalize eligibility verification.

• Detect discrepancies and apply all cost containment strategies to aid in claim adjudication.

• Process complex, non-standard provider refunds and returned checks.

• Examine and interpret medical contract terminology.

• Address inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.

• Ensure compliance with all requirements and guarantee that all payments are executed in accordance with company policies and procedures.

• May provide mentorship to less experienced team members.

⛳️ Requirements

• Minimum of 2 years of experience in medical claim processing.

• At least 2 years of experience in a production environment.

• Prior experience handling overpayments.

• Proven ability to manage multiple tasks competently, accurately, and efficiently.

• Strong communication, organizational, and interpersonal skills.

• Prior experience with DG system claims processing.

• Education: Associate’s degree or equivalent experience (high school diploma or GED + 2 years of relevant experience).

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Comprehensive benefits package designed to promote the physical, emotional, and financial well-being of employees and their families.