Senior Claims Technical Review Specialist

Zenith-American; United States; Remote; USD 57,000 - 66,000; Full time

Benefits offered by this job

Health, Vision & Dental

401(k) with company match

Paid time off

Career growth opportunities

Job summary

Zenith American Solutions is seeking a Claims Technical Review Specialist to perform advanced technical review of all types of health benefit claims in accordance with company guidelines and regulatory requirements. You will handle PHI/PII access per job role, coordinate appeals, predetermination reviews, and TPR activities while maintaining detailed documentation and timely responses.

The role requires a High School Diploma or GED and at least three years of experience in processing group

Qualifications

• Three years of experience processing all types of group health benefit claims.
• In-depth knowledge of benefits claims processing and adjudication principles.
• Experience with HCFA, CPT-4, ICD-10, HCPCS terminology.

Responsibilities

• Performs technical review and analysis of all types of claims to ensure accuracy and adherence to procedures.
• Coordinates appeals through research and documentation; generates denial or approval letters.
• Coordinates predetermination reviews and analyzes benefit allowance and category.
• Performs Third-Party Recovery (TPR) duties and communicates with members, providers, insurers, and attorneys.
• Processes refunds, voids, overpayments, and related claim adjustments and audits.

Skills

Claims processing

Data interpretation

Attention to detail

Verbal and written communication

Mathematical ability

Education

High School Diploma or GED

Tools

MS Office

Claims systems

Job description

Zenith American Solutions is seeking a Claims Technical Review Specialist to perform advanced technical review of all types of health benefit claims in accordance with company guidelines and regulatory requirements. You will handle PHI/PII access per job role, coordinate appeals, predetermination reviews, and TPR activities while maintaining detailed documentation and timely responses.

The role requires a High School Diploma or GED and at least three years of experience in processing group