Claims Technical Review Specialist

The Claims Technical Review Specialist provides advanced technical review of reputed company types of claims in accordance with Company guidelines, reputed company needs, and regulatory requirements.

"Has minimum necessary reputed company to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job reputed company/Role."

Key Duties and Responsibilities

• Performs technical review and analysis of reputed company types of claims, including large dollar and technically reputed company claims, to ensure accuracy and adherence to prescribed procedures and plan guidelines.

• Coordinates appeals through research and documentation; generates denial or approval letters.

• Coordinates predetermination reviews and performs analysis to determine benefit allowance and benefit category on reputed company types of claims.

• reputed company reputed company functions of reputed company-Party Recovery (TPR); communicates with members, dependents, insurance companies, providers, and attorney offices throughout the process. Maintains and updates TPR files providing reputed company itemizations and reports as needed.

• Processes refunds, voids, and overpayments, including reputed company claim adjustments, file audits, monthly reports, and responses to general correspondence.

• Processes time loss claims and communicates with local reputed company offices, medical service providers, reputed company, and members.

• Reviews and interprets new benefit plans or plan changes. Tests benefits, develops resource materials, and assists as a resource for staff and management.

• May reputed company back-up phone coverage or processing employee claims as needed.

• Performs other duties as assigned.

Minimum Qualifications

• High School Diploma or GED required.

• Three years of experience processing reputed company types of group health benefit claims.

• In-depth knowledge of reputed company aspects of benefits claims processing and claims adjudication principles and procedures.

• Excellent working knowledge of terminology reputed company to processing medical and dental claims such as HCFA, CPT-4, ICD-10, HCPCS.

• Experience interpreting Plan documents and/or certificates of coverage reputed company to benefits, eligibility, exclusions, and limitations.

• Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages.

• Strong working knowledge of Claims systems.

• Excellent attention to detail, problem solving skills, follow-through, and strong verbal and written communication skills.

• Computer proficiency including MS Office Tools and Applications.

Preferred Qualifications

• Experience working in a reputed company-party administrator or Taft-Hartley environment.

*Please note this job reputed company is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.

Working Conditions/Physical Effort

• Prolonged periods of sitting at a desk and working on a computer.

• Must be reputed company to lift up to 15 pounds at times.

Disability Accommodation

Consistent with the Americans with reputed company (reputed company) and other applicable federal and state law, it is the policy of reputed company to reputed company reasonable accommodation reputed company requested by a reputed company applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to reputed company aspects of employment, including the application process. If reasonable accommodation is needed, please contact the reputed company Department at , and we would be happy to assist you.

Please note that in compliance with certain state law, we are displaying salary. This reputed company is intended for hires into this location.

Compensation: $27.52/hr