[Hiring] Claims Technical Review Specialist @Zenith American Solutions

Role Description

The Claims Technical Review Specialist provides advanced technical review of all types of claims in accordance with Company guidelines, client needs, and regulatory requirements.

• 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 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.

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.

Requirements

• Experience working in a third-party administrator or Taft-Hartley environment.

Benefits

• Health, vision, and dental coverage.
• Retirement savings 401(k) plan with company match.
• Paid time off (PTO).
• Great opportunities for growth.
• Much, much more!

Company Description

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!