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Benefit Review Specialist

SUMMARY OF POSITION: 

The Benefit Review Specialist services insurance customers by determining insurance coverage and benefits; investigating, examining and resolving medical/dental/life/trip cancellation claims; reviews and responds to appeals on previously adjudicated claims; documenting their actions; maintaining their imaging queues; maintaining quality audit standards and ensuring their outcomes are in compliance with the Certificate of Insurance, Policy and Plan Documents as well as legal and regulatory agencies.  Within the scope of their file handling, a BR Specialist may interact with Insured Members, Dependents, and their Advocates, Medical Providers, Claims Team, Underwriting, Customer Care, Akeso, Legal, Sales, Medical Providers, PPO Networks, Insurance Producers, Carriers and Third Party Entities.

 

ESSENTIAL FUNCTIONS:

Review and analyze files to determine coverage for pre-existing conditions depending on Certificate language

Evaluate Appeals to determine the validity, if further review is required and correct claims determinations have been made

Handling detailed write ups for referring files to Medical Review Team for medical determinations

Process medical, dental, or vision claims if applicable

Interpret and apply specific plan document language as well as determine eligibility for benefits during claims adjudication

Provide verbal and written correspondenceto members, group contacts, agents, and healthcare providers

Assist in creation and revision of work flows, policies and procedures

Work in partnership with management to improve processes through identified system errors and process improvement activities

Prepares reports and documents as it relates to the work

Perform other duties as assigned

 

EDUCATION/LICENSURE & CERTIFICATIONS:

Bachelor’s Degree or equivalent work experience

 

REQUIRED EXPERIENCE:

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Strong computer skills

Knowledge of Microsoft Office (Word, Excel, PowerPoint)

5 Years in medical claims, insurance or medical office experience

Knowledge of various types of medical claims and payment types

Knowledge of Certificate languages

 

PREFERRED EXPERIENCE:

Medical billing/coding

Claims processing

Prior Pre-existing Investigation experience

 

PROFESSIONAL COMPTENCIES:

Initiative – proactive in identifying and resolving problems, reporting discrepancies, suggesting new ideas and seeking process improvements

Excellent Client and Customer service skills

Ability to work independently and as part of a team

Ability to work in a fast-paced, deadline-driven environment

Strong verbal and written communication skills

Strong organizational skills

Capable of managing multiple duties concurrently

 

 

WORK CONDITIONS:

Office environment setting

Able to work comfortably in a desk environment

90+% of the time spent sitting, doing keyboard entry and utilizing a mouse

 

 

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