Claim Benefit Specialist

Full-time - Entry Level

Franklin, TN

Health and Personal Care Retailers

About the position

Fast, accurate claims payment is one of the ways we make a difference in people's lives. Claims professionals work directly with members, doctors and employer groups, providing a friendly and knowledgeable voice at the other end of the phone at times when it's most needed. Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim 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, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Handles phone and written inquiries related to requests for preapprovals/pre-authorizations, reconsiderations, or appeals. Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures. Identifies and reports possible claim overpayments, underpayments and any other irregularities. Performs claim re-work calculations. Makes outbound calls to obtain required information for first claim or reconsideration. Trained and equipped to support call center activity if required, including general member and/or provider inquiries.

Responsibilities

• Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
• Acts as a subject matter expert by providing training, coaching, or responding to complex issues.
• Handles customer service inquiries and problems.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures.
• Handles phone and written inquiries related to requests for preapprovals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim re-work calculations.
• Makes outbound calls to obtain required information for first claim or reconsideration.
• Supports call center activity if required, including general member and/or provider inquiries.

Requirements

• 1-2 years of experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Oral and written communication skills.
• Ability to maintain accuracy and production standards.
• Technical skills.
• Analytical skills.

Nice-to-haves

• 2+ years claim processing experience.
• Understanding of medical terminology.
• Strong knowledge of benefit plans, policies and procedures.

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.
• 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.