Claims Benefit SpecialistPrimary Location: Newark, DE
Additional Locations: DE-Newark Apply
- 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
- Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues
- 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.In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).
- Experience in a quality and production environment.
- Attention to detail.
- Ability to use multiple computer applications at one time.
- Claim processing experience (preferred but not required).
- Medical Terminology Experience (Medical Billing/Coding, Triage, Medical Admin, Patient Scheduler, Pharmacy Techs)
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