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 cost-containment measures
Domain
Health insurance / Medical claims
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Medical claim processing, Medical necessity guidelines application, Eligibility verification, Discrepancy identification, Cost-containment measures, Regulatory compliance, Claim rework calculations, Outbound calling for information gathering
Preferred skills
Self-Funding experience, DG system knowledge
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 overpayments/underpayments, Performs claim rework calculations, Trains and mentors team members, Conducts outbound calls for claims or reconsideration requests
