Senior Claims Benefit Specialist
$38,480–$88,088 year
Remote · United States
Job Summary
Senior Claims Benefit Specialist role focused on reviewing and adjusting SF (self-funded), FI (fully insured), and Reinsurance RX claims; adjudicating complex claims in accordance with processing guidelines; processing provider refunds and returned checks; handling inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals; applying medical necessity guidelines to determine coverage and verify eligibility; identifying discrepancies and applying cost containment measures; performing claim re-work calculations and completing overpayments/underpayments investigations; reviewing provider contracts to confirm whether a claim is overpaid and allocating refunds; ensuring compliance and proper payments; may provide job shadowing to less experienced staff; utilizes all resource materials to manage responsibilities.
Required Qualifications
- 2+ years medical claim processing experience
- Experience in a production environment
- Demonstrated ability to handle multiple assignments competently, accurately, and efficiently
- Effective communications, organizational, and interpersonal skills
- DG system claims processing experience (preferred)
- Associate degree (preferred)
- Education: High School Diploma or GED
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