Senior Claim Benefit Specialist

Job Description: • Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. • Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. • Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. • Reviews pre-specified claims and those that exceed specialist adjudication authority or processing expertise. • Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost-containment measures to support accurate claim adjudication. • Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures. • Identifies and reports potential overpayments, underpayments, and other claim irregularities. • Performs claim rework calculations as needed. • Trains and mentors as needed to enhance team performance and technical proficiency. • Conducts outbound calls to obtain required information for claims or reconsideration requests. Requirements: • Minimum of 18 months of medical claim processing experience with a health insurance payor or third-party administrator. • Proven success working in a high-volume, production-driven environment. • Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail. • 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 for all colleagues 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 Apply To this Job