Claim Benefit Specialist
Our client operates within the healthcare industry, focusing on improving access to connected, convenient, and compassionate health experiences. They address challenges in healthcare delivery by supporting individuals, families, and communities through comprehensive health services and solutions designed to simplify access to care.
About the role
The Claim Benefit Specialist plays a critical role in ensuring accurate and timely healthcare claims processing. This position reviews and adjudicates claims according to established guidelines, applies medical necessity and coverage criteria, and resolves claim discrepancies. The role supports operational efficiency and quality while contributing to accurate claim outcomes and customer satisfaction.
Responsibilities
- Review and adjudicate healthcare claims according to established claim processing guidelines.
- Apply medical necessity guidelines and verify member eligibility.
- Identify discrepancies and apply appropriate cost containment measures during claim adjudication.
- Review claims and referral submissions for accurate coding, member identification, and provider selection.
- Analyze and approve claims requiring manual rework.
- Manage assigned claims within established turnaround times, including processing electronic correspondence.
- Utilize system tools and resources to ensure accurate and efficient claim processing.
Requirements
- 1–2 years of customer service experience.
- Strong teamwork, organizational, and time-management skills.
- Effective written and verbal communication skills.
- Ability to manage multiple assignments while maintaining accuracy and efficiency.
- High school diploma, GED, or equivalent.
Preferred Qualifications
- Experience working in a production environment.
- Ability to navigate multiple systems to research and resolve complex issues.
- Previous claims processing experience preferred but not required.
- Familiarity with medical terminology.
Pay
Typical pay range: $17.00–$25.65 per hour. Actual compensation may vary based on experience, education, geographic location, and other relevant factors.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and additional resources, subject to eligibility.