Claims Technical Review Specialist

Overview

This role is on behalf of a partner company seeking a Claims Technical Review Specialist based in the United States. It offers a chance to apply advanced expertise in claims while ensuring healthcare benefit processing is accurate, compliant, and efficient. The professional will conduct thorough technical evaluations of complex claims, interpret benefit plans, and assist in resolving difficult cases.

Working collaboratively within healthcare administration, this position demands strong analytical attention, detail orientation, and regulatory knowledge. The specialist will uphold high-quality member experiences by ensuring claims decisions are precise, well-documented, and conform to plan requirements.

Accountabilities

• Conduct in-depth technical reviews and analyses of diverse and high-value claims, guaranteeing accuracy according to procedures and plan guidelines.
• Research, document, and manage appeals processes including crafting approval or denial communications.
• Perform predetermination reviews to assess eligibility, coverage details, and benefit categories.
• Handle third-party recovery operations, coordinating with members, providers, insurers, and legal parties.
• Maintain detailed recovery documentation, reports, and files to support claim resolutions.
• Process refunds, adjustments, voids, and overpayments while completing required audits and correspondence.
• Evaluate and manage time-loss claims in cooperation with internal and external stakeholders.
• Interpret new and revised benefit plans, test configurations, develop reference materials, and assist in staff training.
• Provide operational support including claims processing assistance and phone coverage as necessary.
• Ensure confidentiality and proper handling of protected health information (PHI) and personally identifiable information (PII).

Requirements

• High school diploma or GED is mandatory.
• At least three years of experience processing group health benefit claims involving various claim types.
• Thorough understanding of claims processing principles, adjudication, and healthcare benefit management.
• Skill in interpreting plan documents, coverage certificates, eligibility, exclusions, and limitations.
• Knowledge of medical and dental claims terminology including HCFA, CPT-4, ICD-10, and HCPCS codes.
• Experience with claims processing systems and relevant technology platforms.
• Strong analytical, problem-solving, organizational capabilities, and ability to follow through on tasks.
• Excellent written and verbal communication skills for interaction with members, providers, and team members.
• Ability to perform financial calculations involving discounts, percentages, and interest.
• Proficiency in Microsoft Office and business software applications.
• Preferred experience in third-party administrator or Taft-Hartley environments.
• Capability to work autonomously managing time-sensitive and detailed duties.

Compensation and Benefits

• Competitive hourly rate of approximately $27.52.
• Remote work with flexible location options within authorized regions.
• Comprehensive health, dental, and vision insurance packages.
• Retirement plan with employer matching.
• Paid time off to encourage work-life balance.
• Career advancement and professional growth opportunities.
• A supportive and respectful work culture focused on employee well-being.
• A chance to contribute meaningfully to healthcare service quality and member impact.
• Employment with a stable organization dedicated to service excellence.