Senior Claims Technical Review Analyst

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

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.