Senior Claim Benefit Specialist Operations (Encounters)
Core
Researches, reviews, and adjudicates complex, sensitive, and specialized medical encounters to ensure accurate claim processing in accordance with state-specific guidelines.
Role type
Senior claims adjudication specialist (medical encounters)
Builds
Accurate claim payments and encounter corrections for Medicaid, Medicare, and Commercial plans
Domain
Health insurance / Medical claims processing
Required skills
Medical claims processing, State-specific guideline adherence, Claims adjudication, Error resolution, Cross-functional collaboration, Procedure documentation
Preferred skills
QNXT system, Facets system, Edifecs system, Medicaid/Medicare specific experience
Technologies
MS Office Suite (Excel, Word, OneNote), QNXT, Facets, Edifecs
Responsibilities
Adjudicate complex and specialized claims with accuracy, Identify and escalate issues impacting claim payment accuracy, Partner cross-functionally to resolve barriers to encounter acceptance, Contribute to the development of standardized procedures
Seniority
Senior, hands-on IC