Claim Benefit Specialist- Franklin, TN.
Core
Analyze and process routine claims that cannot be auto-adjudicated, applying medical necessity and coverage guidelines to support accurate claim decisions.
Role type
Claims adjudication specialist
Builds
Accurate claims payment decisions for members, doctors, and employer groups
Domain
Health insurance / Claims processing
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Claims adjudication, Medical necessity guidelines, Eligibility verification, Cost-containment measures, Claims systems workflows, Compliance review, Procedure/diagnosis validation, Queue management
Preferred skills
Claim processing experience, Medical terminology, Benefit plans knowledge
Technologies
Claim Check, Reasonable and customary data, Post-containment resources
Responsibilities
Analyze and process routine claims, Apply medical necessity and coverage guidelines, Verify member eligibility, Respond to routine claim-related inquiries, Route complex claims to senior team members, Review claims for compliance
Seniority
Entry-level, hands-on IC
