Claims Technical Review Specialist, Sr.

Position Summary

The Claims Technical Review Specialist, Sr provides advanced quality review of claims processing and delivers practical training to improve team effectiveness and efficiency 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


* Reviews the work of new hires and existing employees; audits claims processing to identify areas for individual performance improvement; provides instructional feedback to increase team members' skill level in claims processing.


* 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.


* Identifies potential procedural or system issues and suggests possible solutions for process and quality improvements to management.


* Delivers practical training to new and existing employees on systems, plans, policies, and procedures.

Updates training aids as needed.


* Tests new plan benefits or changes loaded into the claims system to ensure accuracy, adherence to plan guidelines, and system integrity.


* Completes and submits internal tickets to resolve claims adjustment errors or request claims system enhancements.


* Assists in the maintenance and upkeep of job aids and SOP's.


* Performs other duties as assigned.

Minimum Qualifications


* High school diploma or GED.


* Five years of experience processing all types of group health benefit claims.


* Experience working in a third-party administrator or Taft-Hartley environment.


* 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.


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


* Proven ability to work independently and deliver results.


* Strong working knowledge of Claims systems.


* Excellent written and oral communication skills.


* Computer proficiency including Microsoft Office tools and applications.

Preferred Qualifications


* Experience as a practical trainer.



*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 notic...