Benefit Review Specialist

Delta Health Systems

. Research facts and circumstances related to Plan Participant and Provider complaints, appeals, and grievances .

Posted 10/20/2026part-timeStockton • California • United StatesMid-LevelSenior💰 $24 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in interpreting and applying medical coding standards, including AMA, CPT, CDT, HCPCS, and ICD10, while effectively managing appeals and grievances. Proficient in system configuration and documentation processes to ensure compliance with plan provisions and regulatory guidelines.

Highest-signal resume keywords

Medical Coding ExpertiseSystem Configuration KnowledgeStrong Written And Verbal CommunicationAbility To Interpret Medical TerminologyOrganizational Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical CodingSystem ConfigurationData AnalysisPlan Document InterpretationClaims ProcessingAppeals ManagementExcel ProficiencyWord ProficiencyUnderstanding Of NAIC RegulationsUnderstanding Of CMS Guidelines

Soft Skills

Strong Communication SkillsGood Organizational SkillsAbility To Work Under PressureComprehension SkillsAbility To Work Independently

Industry Keywords

Coordination Of BenefitsThird-Party LiabilityUsual And Customary ConceptsNetwork PricingClaim CalculationPlan BenefitsCovered ServicesSelf-Funding Plan DocumentsDental X-RaysPerio Charts

About the role

Key responsibilities & impact

Research facts and circumstances related to Plan Participant and Provider complaints, appeals, and grievances
Apply contract language, benefits, covered services, Self-Funding Plan Documents, NAIC Regulations, and CMS Guidelines to determine accurate resolutions
Perform system configuration related to plan provision requirements in collaboration with Plan Build Benefits
Handle phone inquiries from Plan Participants, Providers, and Internal Departments
Interpret and explain plan benefits, policies, procedures, and functions to participants and internal and external customers
Perform standard department metrics based on established goals and objectives
Log appeals in Excel and document claim notes and final determinations
Review receipts and appeals to determine complaint validity
Scan and send supporting documentation to HCI for edited-code review and determination
Respond to HCI determinations by letter or process claim adjustments
Review medical notes and plan documents to determine appeal outcomes
Write letters requesting information or explanations of payment issues
Create accurate acknowledgment and resolution letters
Ensure claim documentation is imaged and documented appropriately
Answer questions from customer service and processors regarding claim processing, plan documents, and denial logic
Research online sources, plan documents, coding manuals, and external resources to resolve difficult appeals
Review claims and appeals in a timely manner
Collaborate internally to ensure system configuration meets medical policy guidelines and plan provisions
Perform other duties as required

Requirements

What you’ll need

Strong understanding of American Medical Association (AMA), CPT, CDT, HCPCS, Revenue, and ICD10 coding (medical and dental)
Knowledge of Coordination of Benefits (COB)
Knowledge of Third-Party Liability (TPL)
Advanced computer skills, particularly in Word and Excel, and basic knowledge of database applications
Strong written and verbal communication skills
Good organizational skills and ability to work well under pressure
Ability to interpret medical and dental terminology
Ability to read and interpret dental X-rays, Perio Charts, and Narrative Reports
Ability to read, understand, and interpret Client Summary Plan Documents, NAIC Regulations and Guidelines, CMS Guidelines, and Network Medical Policies
Understanding of Usual and Customary concepts, network pricing, claim calculation, and validation
Ability to work independently
Strong comprehension skills and understanding of technical issues
Knowledge of plan benefits, covered services, and benefit application
Knowledge of system configuration specific to plan provision requirements
Any employee who is not in a probationary status and meets the qualifications may apply; internal applicants must submit a letter and current resume to Human Resources