Claims Technical Review Specialist

This role provides an opportunity to apply advanced claims expertise while ensuring accurate, compliant, and efficient healthcare benefit processing. The successful candidate will perform detailed technical reviews of complex claims, interpret benefit plans, and support resolution of challenging cases within a collaborative healthcare administration environment.

About the role

The Claims Technical Review Specialist conducts advanced claims analysis, ensuring accurate adjudication, compliance with benefit guidelines, and effective resolution of complex claim-related matters. You will contribute to high-quality member experiences by ensuring claims decisions are accurate, well-documented, and aligned with plan requirements.

Responsibilities

• Perform technical reviews and detailed analysis of various claim types, including high-dollar and complex claims, ensuring accuracy and adherence to established procedures and plan requirements.
• Research, document, and coordinate appeals while preparing appropriate approval or denial communications.
• Conduct predetermination reviews to evaluate benefit eligibility, coverage allowances, and applicable benefit categories.
• Manage third-party recovery activities, including communication with members, dependents, providers, insurance companies, and legal representatives.
• Maintain recovery documentation, itemizations, reports, and related files to support accurate claim resolution.
• Process refunds, claim adjustments, voids, and overpayments while completing audits, reports, and correspondence responses.
• Review and process time-loss claims while coordinating with relevant external and internal stakeholders.
• Interpret new benefit plans and plan modifications, test benefit configurations, develop reference materials, and support staff training.
• Provide additional operational support, including claim processing assistance and phone coverage when needed.
• Maintain confidentiality and appropriately handle protected health information (PHI) and personally identifiable information (PII).

Requirements

• High school diploma or GED required.
• Minimum of 3 years of experience processing group health benefit claims across various claim types.
• Strong knowledge of claims processing principles, adjudication procedures, and healthcare benefit administration.
• Experience interpreting plan documents, certificates of coverage, eligibility requirements, exclusions, and benefit limitations.
• Familiarity with medical and dental claims terminology, including HCFA, CPT-4, ICD-10, and HCPCS codes.
• Experience using claims processing systems and related technology platforms.
• Strong analytical, problem-solving, organizational, and follow-through skills.
• Excellent written and verbal communication abilities with the ability to interact effectively with members, providers, and internal teams.
• Ability to perform calculations involving discounts, percentages, interest, and other financial figures.
• Proficiency with Microsoft Office tools and business applications.
• Experience in a third-party administrator or Taft-Hartley environment is preferred.
• Ability to work independently while managing detailed and time-sensitive responsibilities.

Benefits

• Competitive compensation of approximately $27.52 per hour.
• Remote work opportunity with location flexibility within approved regions.
• Comprehensive health, dental, and vision insurance coverage.
• Retirement savings plan with employer matching contributions.
• Paid time off (PTO) to support work-life balance.
• Opportunities for career growth, development, and internal advancement.
• Supportive work environment focused on collaboration, respect, and employee well-being.
• Opportunity to contribute to meaningful healthcare administration services impacting members and clients.
• Stable organization with a strong history and commitment to service excellence.