索赔技术审查专员
Claims Technical Review Specialist
职位概述
理赔技术审核专员根据公司指南、客户要求和监管要求，对各类理赔进行高级技术审核。
“根据职位描述/岗位职责，仅具备必要的访问受保护健康信息（PHI）和个人可识别信息（PII）的权限。”
主要职责和任务
- 对各类理赔，包括大额和复杂技术性理赔进行技术审核和分析，确保准确性和遵循既定程序和计划指南。
- 协调申诉流程，通过研究和记录；生成拒赔或批准信件。
- 协调预确定审核并进行分析，以确定各类理赔的福利允许金额和福利类别。
- 执行第三方追偿（TPR）所有职能；在过程中与成员、家属、保险公司、提供者和律师事务所沟通。维护和更新TPR文件，按需提供相关明细和报告。
- 处理退款、作废和超额支付，包括相关理赔调整、文件审计、月度报告和一般信函的回复。
- 处理工时损失理赔，并与当地工会办公室、医疗服务提供者、雇主和成员进行沟通。
- 审核和解释新的福利计划或计划变更。测试福利，开发资源材料，并作为员工和管理层的资源协助。
- 可能提供备用电话支持或根据需要处理员工理赔。
- 完成其他指派的任务。
最低资格要求
- 需要高中文凭或同等学历。
- 三年处理各类团体健康福利理赔的经验。
- 熟悉福利理赔处理的所有方面以及理赔裁定原则和程序。
- 精通与医疗和牙科理赔处理相关的术语，如HCFA、CPT-4、ICD-10、HCPCS。
- 有解读与福利、资格、排除和限制相关的计划文件和保险证明的经验。
- 能够计算折扣、利息、比例和百分比等数字。
- 熟练掌握理赔系统。
- 优秀的细节关注能力、解决问题的能力、执行力以及良好的口头和书面沟通能力。
- 熟练使用计算机，包括MS Office工具和应用。
查看英文原文
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
- Prolonged periods of sitting at a desk and working on a computer.
- Must be able to lift up to 15 pounds at times.
Disability Accommodation
Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at , and we would be happy to assist you.
Please note that in compliance with certain state law, we are displaying salary. This rate is intended for hires into this location.
Compensation: $27.52/hr
Zenith American Solutions
Real People. Real Solutions. National Reach. Local Expertise.
We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.
Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before.
We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American!
We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!
Originally posted on Himalayas