Senior Claim Benefit Specialist - Remote
Core
Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines.
Role type
Senior Claim Benefit Specialist
Builds
Accurate claim adjudication and member experience
Domain
Health insurance / Medical claims
Required skills
Medical claim processing, Medical necessity guidelines application, Eligibility verification, Cost-containment measures, Regulatory compliance, Claim rework calculations, Outbound calling for information, Mentoring and training
Preferred skills
Self-Funding experience, DG system knowledge
Technologies
DG system
Responsibilities
Reviews pre-specified claims and those exceeding specialist authority; Applies medical necessity guidelines and determines coverage; Ensures compliance with regulatory requirements; Identifies and reports claim irregularities; Performs claim rework calculations; Trains and mentors team members; Conducts outbound calls for claims information.
Seniority
Senior, hands-on IC