Claim Benefit Specialist

About the position

Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills.

Responsibilities

• Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
• Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope.
• Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.
• Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims.
• Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution.
• Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
• Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies.
• Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
• Analyzes claims data and generate reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.
• Review claims or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.
• Analyzes and processes rework claims that cannot be auto adjudicated.
• In accordance with prescribed operational guidelines, manages route list/queues.
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service.

Requirements

• Possess strong teamwork and organizational skills.
• Strong and effective communication skills.
• Ability to handle multiple assignments competently through use of time management, accurately and efficiently.
• Strong proficiency using computers and experience with data entry.

Nice-to-haves

• Experience in a production environment.
• Healthcare experience.
• Knowledge of utilizing multiple systems at once to resolve complex issues.
• Claim processing experience preferred but not required.
• Understanding of medical terminology.

Benefits

• Full range of medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Employee Stock Purchase Plan.
• Fully-paid term life insurance plan.
• Short-term and long-term disability benefits.
• Numerous well-being programs.
• Education assistance.
• Free development courses.
• CVS store discount.
• Discount programs with participating partners.
• Paid Time Off (PTO) or vacation pay.
• Paid holidays throughout the calendar year.