Claims Benefit Specialist

Claims Benefit Specialist

Requirements

• 1-2 Years within the following; Experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Oral and written communication skills.
• Ability to maintain accuracy and production standards.
• Technical skills.
• Analytical skills.

Responsibilities

• Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim 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 preapprovals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim re-work calculations.
• Makes outbound calls to obtain required information for first claim or reconsideration.
• Trained and equipped to support call center activity if required, including general member and/or provider inquiries.

Preferred Qualifications

• 2+ years claim processing experience.
• Understanding of medical terminology.
• Strong knowledge of benefit plans, policies and procedures.