Senior Claim Benefit Specialist

Job reputed company: • Reviews and adjudicates reputed company, 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 reputed company member experience. • Reviews reputed company‑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 reputed company regulatory requirements and confirms that payments reputed company 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 reputed company‑party administrator. • Proven reputed company 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: • medical, dental, and reputed company coverage • reputed company time off • retirement savings reputed company • wellness programs Apply tot his job Apply To this Job