Claims Technical Review Specialist

Position Summary

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

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

Key Duties and Responsibilities


* Performs technical review and analysis of all types of claims, including large dollar and technically complex 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 all types of claims.


* Perform all functions of Third-Party Recovery (TPR); communicates with members, dependents, insurance companies, providers, and attorney offices throughout the process.

Maintains and updates TPR files providing related itemizations and reports as needed.


* Processes refunds, voids, and overpayments, including related claim adjustments, file audits, monthly reports, and responses to general correspondence.


* Processes time loss claims and communicates with local union offices, medical service providers, employers, 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 provide 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 all types of group health benefit claims.


* In-depth knowledge of all aspects of benefits claims processing and claims adjudication principles and procedures.


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


* Experience interpreting Plan documents and/or certificates of coverage related 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 third-party administrator or Taft-Hartley environment.



*Please note this job description 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


* Prolon...