Job Description
Reviews and adjudicates claims for individual family plans.
Claim Benefit Specialists have the opportunity to enhance and improve member satisfaction and retention by providing accurate and timely resolution in processing medical claims. You will be a key link in providing our customers with prompt, efficient, high quality claim service.
• Determine and understand the coverage provided under a member’s health plan
• Efficiently use multiple systems and screens to obtain and record claim information
• Review claims information to determine the nature of a member’s illness or injury
• Identify claim cost management opportunities and refer claims for follow up
• Make claim payment decisions
• Process claims accurately to enhance customer satisfaction and retention
• Process claims within quality and production standards
• Assist team members in support of achieving team, office, regional, and national goals
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Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.90
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
Required Qualifications :
Attendance during the 20 week training period is required.
Experience in a quality and production environment.
Attention to detail.
Ability to use multiple computer applications at one time.
Claim processing experience.
Analyzes and approves routine claims that cannot be auto adjudicated.
Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
Routes and triages complex claims to Senior Claim Benefits Specialist.
Proofs claim 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.
May facilitate training when considered topic subject matter expert.
Utilizes all applicable system functions available ensuring accurate and timely claim processing service.
Preferred Qualifications
Strong oral and written communication skills.
Ability to maintain accuracy and production standards.
Technical skills.
Attention to detail and accuracy.
Analytical skills.
Ability to Multi-Task
Education
High School Diploma or GED equivalent
