Senior Claim Benefit Specialist

Description: • Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines • Acts as a subject matter expert by providing training, coaching, or responding to complex issues • May handle customer service inquiries and problems • Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise • Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process • Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals • Ensures all compliance requirements are satisfied and all payments are made against company practices and procedures • Identifies and reports possible claim overpayments, underpayments, and any other irregularities • Performs claim rework calculations • Distributes work assignment daily to junior staff • Trains and mentors claim benefit specialists • Makes outbound calls to obtain required information for claim or reconsideration Requirements: • 18+ months of medical claim processing experience • Experience in a production environment • Demonstrated ability to handle multiple assignments competently, accurately and efficiently • Self-Funding experience (preferred) • DG system knowledge (preferred) • High School Diploma required • Preferred Associates degree or equivalent work experience Benefits: • Affordable medical plan options • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs including wellness screenings, tobacco cessation, and weight management programs • Confidential counseling and financial coaching • Paid time off • Flexible work schedules • Family leave • Dependent care resources • Colleague assistance programs • Tuition assistance • Retiree medical access Apply tot his job