Actual Job Title - Seasonal Claims Benefit Specialist
Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.
Reviews and adjudicates routine claims in accordance with claim processing guidelines.
Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)
• 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 production environment.
• Claim processing experience.
Education and Certification Requirements
High School or GED equivalent.
Additional Information (situational competencies, skills, work location requirements, etc.)
• Ability to maintain accuracy and production standards.
• Analytical skills.
• Technical skills.
• Oral and written communication skills.
• Understanding of medical terminology.
• Attention to detail and accuracy.