Claim Benefit Specialist

About the role

Reviews and adjudicates claims in accordance with claim processing guidelines. Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.

Review claims or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements. Analyzes and approves rework claims that cannot be auto adjudicated.

In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System—system used to process correspondence that is scanned in the system by a vendor). Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).

Responsibilities

• Adjudicate claims following claim processing guidelines.
• Apply medical necessity guidelines and determine coverage.
• Complete eligibility verification and identify discrepancies.
• Apply cost containment measures during claim adjudication.
• Review claims or referral submissions for appropriate guidelines, coding, and member/provider identification.
• Analyze and approve rework claims that cannot be auto-adjudicated.
• Manage claims on desk, route/queues, and ECHS within specified turn-around-time parameters.
• Utilize system functions (e.g., Claim Check, reasonable and customary data) for accurate and timely claim processing.

Requirements

• 1-2 years of experience working in customer service.
• Strong teamwork and organizational skills.
• Strong and effective communication skills.
• Ability to handle multiple assignments competently through time management.

Preferred Qualifications

• Experience in a production environment.
• Knowledge of utilizing multiple systems simultaneously to resolve complex issues.
• Claim processing experience (preferred but not required).
• Understanding of medical terminology.

Education

High School diploma, GED, or equivalent experience.

Pay

The typical pay range for this role is $17.00 - $25.65 per hour. The actual base salary offer will depend on factors including experience, education, geography, and other relevant considerations.

Schedule

• Full-time.
• 40 anticipated weekly hours.

Benefits

This full-time position is eligible for a comprehensive benefits package, including:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources.