Claims Technical Review Specialist
$57,242–$57,242 year
RemoteUnited States
Job Summary
Conduct advanced technical review and analysis of all types of claims, including large dollar and complex cases, to ensure accuracy and adherence to prescribed procedures. Coordinate appeals through research and documentation, generating denial or approval letters, while performing analysis for predetermination reviews to determine benefit allowances. Execute Third-Party Recovery functions by communicating with members, providers, and attorney offices, maintaining files, and processing refunds, voids, and overpayments. Review new benefit plans, test benefits, and develop resource materials. Perform back-up phone coverage or processing employee claims as needed. Requires three years of experience processing group health benefit claims, strong knowledge of medical and dental terminology (HCFA, CPT-4, ICD-10), and proficiency in Claims systems. Salary is $27.52/hr. Zenith American Solutions is the largest independent Third Party Administrator in the United States.
Required Qualifications
- High School Diploma or GED
- Three years of experience processing all types of group health benefit claims
- In-depth knowledge of all aspects of benefits claims processing and claims adjudication principles and procedures
- Excellent working knowledge of terminology related to processing medical and dental claims such as HCFA, CPT-4, ICD-10, HCPCS
- Experience interpreting Plan documents and/or certificates of coverage related to benefits, eligibility, exclusions, and limitations
- Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages
- Strong working knowledge of Claims systems
- Excellent attention to detail
- Problem solving skills
- Follow-through
- Strong verbal and written communication skills
- Computer proficiency including MS Office Tools and Applications
- Must be able to lift up to 15 pounds at times
Desired Qualifications
- Experience working in a third-party administrator or Taft-Hartley environment
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