Accountabilities:

The Claims Technical Review Specialist is responsible for conducting advanced claims analysis, ensuring accurate adjudication, compliance with benefit guidelines, and effective resolution of complex claim-related matters.

• Perform technical reviews and detailed analysis of various claim types, including high-dollar and complex claims, ensuring accuracy and adherence to established procedures and plan requirements.
• Research, document, and coordinate appeals while preparing appropriate approval or denial communications.
• Conduct predetermination reviews to evaluate benefit eligibility, coverage allowances, and applicable benefit categories.
• Manage third-party recovery activities, including communication with members, dependents, providers, insurance companies, and legal representatives.
• Maintain recovery documentation, itemizations, reports, and related files to support accurate claim resolution.
• Process refunds, claim adjustments, voids, and overpayments while completing audits, reports, and correspondence responses.
• Review and process time-loss claims while coordinating with relevant external and internal stakeholders.
• Interpret new benefit plans and plan modifications, test benefit configurations, develop reference materials, and support staff training.
• Provide additional operational support, including claim processing assistance and phone coverage when needed.
• Maintain confidentiality and appropriately handle protected health information (PHI) and personally identifiable information (PII).

Requirements:

The ideal candidate will bring strong healthcare claims experience, technical knowledge, and the ability to analyze complex benefit information while maintaining accuracy and compliance.

• High school diploma or GED required.
• Minimum of 3 years of experience processing group health benefit claims across various claim types.
• Strong knowledge of claims processing principles, adjudication procedures, and healthcare benefit administration.
• Experience interpreting plan documents, certificates of coverage, eligibility requirements, exclusions, and benefit limitations.
• Familiarity with medical and dental claims terminology, including HCFA, CPT-4, ICD-10, and HCPCS codes.
• Experience using claims processing systems and related technology platforms.
• Strong analytical, problem-solving, organizational, and follow-through skills.
• Excellent written and verbal communication abilities with the ability to interact effectively with members, providers, and internal teams.
• Ability to perform calculations involving discounts, percentages, interest, and other financial figures.
• Proficiency with Microsoft Office tools and business applications.
• Experience in a third-party administrator or Taft-Hartley environment is preferred.
• Ability to work independently while managing detailed and time-sensitive responsibilities.

Benefits:

• Competitive compensation of approximately $27.52 per hour.
• Remote work opportunity with location flexibility within approved regions.
• Comprehensive health, dental, and vision insurance coverage.
• Retirement savings plan with employer matching contributions.
• Paid time off (PTO) to support work-life balance.
• Opportunities for career growth, development, and internal advancement.
• Supportive work environment focused on collaboration, respect, and employee well-being.
• Opportunity to contribute to meaningful healthcare administration services impacting members and clients.
• Stable organization with a strong history and commitment to service excellence.