Senior Claim Benefit Specialist
Description:
- Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines.
- Acts as a subject matter expert by providing training, coaching, or responding to complex issues.
- May handle customer service inquiries and problems.
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
- Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
- Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
- Insures all compliance requirements are satisfied and all payments are made against company practices and procedures.
- Identifies and reports possible claim overpayments, underpayments and any other irregularities.
- Performs claim rework calculations.
- Distributes work assignment daily to junior staff.
- Trains and mentors claim benefit specialists.
- Makes outbound calls to obtain required information for claim or reconsideration.
Requirements:
- 2+ years claim processing experience.
- Experience in a production environment.
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
- Self funded medical claim processing experience (Preferred)
- DG system knowledge (Preferred)
Benefits:
- Affordable medical plan options
- A 401(k) plan (including matching company contributions)
- An employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
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