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 in compliance with NAIC and CMS guidelines. Strong communication and organizational skills are essential for collaborating with internal departments and addressing inquiries from plan participants and providers.

Highest-signal resume keywords

Medical Coding ExpertiseKnowledge of Coordination of Benefits (COB)Advanced Excel SkillsStrong Written and Verbal Communication SkillsAbility to Interpret Medical Terminology

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Coding (AMA, CPT, CDT, HCPCS, ICD10)Coordination of Benefits (COB)Third-Party Liability (TPL)Claim Calculation and ValidationDatabase ApplicationsReading Dental X-RaysInterpreting Client Summary Plan DocumentsUnderstanding NAIC RegulationsUnderstanding CMS GuidelinesUsual and Customary Concepts

Soft Skills

Strong Organizational SkillsAbility to Work Under PressureStrong Comprehension SkillsAbility to Work Independently

Tools & Technologies

Microsoft WordMicrosoft Excel

Industry Keywords

Plan Participant ComplaintsProvider ComplaintsGrievancesSelf-Funding Plan DocumentsMedical Policy GuidelinesPlan Provision Requirements

About the role

Key responsibilities & impact

Research facts and circumstances related to Plan Participant and Provider complaints, appeals, and grievances
Apply contract language, benefits, and covered services to determine accurate and appropriate resolutions
Follow Self-Funding Plan Documents, NAIC Regulations, and CMS Guidelines
Configure systems for 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 customers
Perform standard department metrics based on established goals and objectives
Log appeals in Excel, document claim notes, and record final determinations
Review work-in-order receipts and 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 information-request and payment-explanation letters
Create accurate acknowledgment and resolution letters
Ensure claim documentation is imaged and documented appropriately
Answer questions from customer service and processors about claims, plan documents, and denial logic
Research online sources, plan documents, coding manuals, and external resources to resolve difficult appeals
Collaborate with internal departments 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, with 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
Any employee not in probationary status who meets the qualifications may apply