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Claim Benefit Specialist ID-20885

📋 Description

• Reviews and adjudicates routine claims in accordance with claim processing guidelines. • Ability to work independently. • Ability to think logically and problem solve. • Strong oral communication skills. • Analyzes and approves routine claims that cannot be auto adjudicated. • Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process. • Routes and triages complex claims to Senior Claim Benefits Specialist. • Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements. • Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. • Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. • Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. • Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. • Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims. • Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development. • Analyzes claims data and generates reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.

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🎯 Requirements

• Less than 1 year work experience • Working knowledge of problem solving and decision making skills • Experience in a production environment. • Medical claim processing experience (preferred) • Medical coding background (preferred) • Experience with Excel, Word, Teams and Outlook (preferred)

🏖️ Benefits

• Affordable medical plan options • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs including wellness screenings, tobacco cessation, weight management programs, confidential counseling and financial coaching. • Paid time off • Flexible work schedules • Family leave • Dependent care resources • Colleague assistance programs • Tuition assistance • Retiree medical access

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