Claims Technical Review Specialist

Zenith American Solutions; United States; Remote; USD 31,000 - 45,000; Full time

Benefits offered by this job

Health benefits

401(k) retirement plan

Job summary

Zenith American Solutions is seeking a Claims Technical Review Specialist to perform advanced technical review of health benefit claims in line with company guidelines, client needs, and regulatory requirements.

The role includes coordinating appeals, predetermination reviews, and Third-Party Recovery, while ensuring accurate analyses, timely documentation, and secure handling of PHI/PII. Strong knowledge of claims systems and MS Office is required.

Qualifications

• Three years of experience processing all types of group health benefit claims.
• In-depth knowledge of benefits claims processing and adjudication principles and procedures.
• Experience interpreting Plan documents and/or certificates of coverage related to benefits, eligibility, exclusions, and limitations.
• Knowledge of HCFA, CPT-4, ICD-10, HCPCS.
• Ability to calculate discounts, interest, proportions, and percentages.
• Strong working knowledge of Claims systems.
• Excellent attention to detail, problem solving, and communication.
• MS Office proficiency.

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.
• Performs other duties as assigned; participates in Third-Party Recovery (TPR) processes and maintains related files.
• Processes refunds, voids, and overpayments, including related claim adjustments and audits.
• 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 and prepares resource materials.
• May provide back-up phone coverage or processing employee claims as needed.

Skills

Technical review

Claims processing

Analytical skills

Documentation

Communication

Education

High School Diploma or GED

Tools

Claims systems

MS Office

Job description

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 [e-mail], 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!