Senior Claim Benefit SpecialistPrimary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix Apply
- 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 pre-approvals/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.Distributes work assignments daily to junior staff.
- Trains and mentors claim benefit specialists.Makes outbound calls to obtain required information for First claim or re-consideration.
- Trained and equipped to support call center activity if required, including general member and/or provider inquiries.
- Experience in a production environment.
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
- 2+ years claim processing experience.
- Claim processing experience.
- Associate's degree or equivalent work experience.
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