Claim Specialist

• Handle and process benefits claims submitted by healthcare providers
• Determine benefit eligibility and coverage based on insurance plans and policy guidelines
• Assess claims for accuracy, coding compliance, medical necessity, and documentation requirements
• Document claim information, codes, modifiers, and other data in company systems
• Review and investigate claims requiring additional scrutiny or validation
• Communicate with healthcare providers, patients, and stakeholders to resolve discrepancies
• Ensure claims processing complies with regulatory requirements, industry standards, and company policies
• Review and adjudicate routine claims according to processing guidelines
• Analyze and approve routine claims that cannot be auto-adjudicated
• Apply medical necessity guidelines, verify eligibility, identify discrepancies, and apply cost-containment measures
• Coordinate responses to routine phone inquiries and written correspondence
• Route and triage complex claims to the Senior Claim Benefits Specialist
• Proof claim or referral submissions and apply appropriate guidelines, coding, member identification, diagnosis, and pre-coding requirements
• Facilitate training when serving as a subject matter expert
• Manage claims, queues, and ECHS within specified turnaround-time parameters
• Use applicable system functions, including claim check, reasonable and customary data, and post-containment tools
• Develop and implement feedback and performance review processes
• Analyze claims data and generate reports to identify trends and improvement opportunities

Claim Benefit Specialist

• Review and rework sensitive, complex medical and hospital claims for the rework project department.
• Work closely with Commercial Services Operations team members to perform root cause analysis and precisely resolve affected claims.
• Ensure rework project claims are resolved accurately and handled by the rework project due date.
• Serve as a medical/hospital claim processor for rework projects, compliance, and complex issues.
• Process claims for specific providers/networks or large-scale rework projects resulting from plan sponsor issues, release fallout, and legal, regulatory, or compliance concerns.
• Interface with appropriate areas to resolve claims.

• Review and rework sensitive, complex medical and hospital claims for the rework project department
• Work closely with Commercial Services Operations team members to perform root cause analysis and precisely resolve affected claims
• Ensure rework project claims are resolved accurately
• Interface with appropriate areas to address claims
• Complete rework project claims by the due date
• Serve as a medical/hospital claim processor for rework projects, compliance, and complex issues
• Process claims for specific providers/networks or large-scale rework projects resulting from plan sponsor issues, release fallout, and legal, regulatory, or compliance concerns