Claim Benefit Specialist

About the Role

Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills.

Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.

Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.

Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies. Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development. Analyzes claims data and generates reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.

Responsibilities

• Review and document claims
• Verify policy coverage and assess claim validity
• Communicate with healthcare providers and policyholders
• Ensure accurate and timely claims processing
• Process Benefits claims with accuracy and efficiency
• Determine eligibility and coverage based on insurance plans and policy guidelines
• Assess claims for compliance with coding guidelines and medical necessity
• Document claim information in company systems with appropriate codes and modifiers
• Conduct reviews and investigations of claims requiring additional scrutiny
• Resolve discrepancies or issues with healthcare providers, patients, or stakeholders
• Ensure compliance with regulatory requirements and company policies
• Develop and implement feedback and performance review processes
• Analyze claims data and generate reports to identify trends and areas for improvement

Requirements

• 1 year of work experience
• Working knowledge of problem-solving and decision-making skills
• High school diploma or equivalent required

Preferred Qualifications

• ACAS knowledge

Pay

The typical pay range for this role is $17.00 - $25.65 per hour. This pay range represents the base hourly rate for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors.

Schedule

• Full time
• 40 hours per week

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families, including:

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility