Claims Technical Review Specialist
New
J
JobgetherHealthcare Administration
Based in United StatesFull-TimeMiddle
Salary27.52 USD per hour
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Job Details
- Experience
- Minimum of 3 years of experience
- Required Skills
- Data AnalysisMicrosoft Office
Requirements
- High school diploma or GED.
- Minimum of 3 years of experience processing group health benefit claims.
- Strong knowledge of claims processing principles, adjudication procedures, and healthcare benefit administration.
- Ability to interpret plan documents, certificates of coverage, and benefit limitations.
- Familiarity with medical and dental terminology, including HCFA, CPT-4, ICD-10, and HCPCS codes.
- Experience using claims processing systems and related technology platforms.
- Strong analytical, problem-solving, and organizational skills.
- Proficiency with Microsoft Office tools.
- Ability to perform calculations involving discounts, percentages, and interest.
- Experience in a third-party administrator or Taft-Hartley environment is preferred.
Responsibilities
- Perform technical reviews and detailed analysis of complex and high-dollar claims.
- Research, document, and coordinate appeals while preparing approval or denial communications.
- Conduct predetermination reviews to evaluate benefit eligibility, coverage allowances, and benefit categories.
- Manage third-party recovery activities and communications with stakeholders.
- Process refunds, claim adjustments, voids, and overpayments while conducting audits.
- Review and process time-loss claims in coordination with internal and external stakeholders.
- Interpret new benefit plans, test configurations, develop reference materials, and support staff training.
- Maintain confidentiality of PHI and PII while performing daily administrative duties.
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