Senior Claims Benefit Specialist
Core
Review and adjust self-funded, fully insured, reinsurance, and pharmacy claims; adjudicate complex, sensitive, and specialized claims in accordance with processing guidelines.
Role type
Senior Claims Benefit Specialist
Builds
Claim adjudication decisions and payment adjustments for health insurance plans
Domain
Health Insurance / Claims Processing
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical claim processing, claim adjudication, eligibility verification, cost containment measures, contract interpretation, overpayment/underpayment resolution, provider refund processing, appeals handling
Preferred skills
DG system claims processing experience
Technologies
DG system
Responsibilities
Review and interpret medical contract language to confirm claim overpayments and allocate refunds; Handle telephone and written inquiries regarding pre-approvals, reconsiderations, or appeals; Process complex non-routine provider refunds and returned checks; Perform claim re-work calculations and follow through on irregularities; Apply medical necessity guidelines and cost containment measures to assist in claim adjudication.
Seniority
Mid-level, hands-on IC
