[Hiring] Specialist Benefit Review @DELTA HEALTH SYSTEMS MCC

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Delta Health Systems Benefit Review Specialist performs comprehensive research related to the facts and circumstances of Plan Participant and Provider complaints, appeals, and grievances. This position is required to apply contract language, benefits, and covered services in researching and providing an accurate and appropriate resolution following Self-Funding Plan Documents, NAIC Regulations, and CMS Guidelines. • Handle phone inquiries from Plan Participants, Providers, and Internal Departments. • Ability to interpret medical and dental terminology. • Strong understanding of CPT, CDT, HCPCS, Revenue, and ICD10 coding structures. • Read and interpret dental X-rays, Perio Charts, and Narrative Reports. • Ability to read, understand and interpret Client Summary Plan Documents, NAIC Regulations and Guidelines, CMS Guidelines, and Network Medical Policies. • Have good organizational skills and the ability to manage time and resources effectively. • Ability to work independently with strong comprehension skills. • Understand Usual and Customary concepts, network pricing, claim calculation, and validation. • Complies with department policies and procedures. • Knowledge of Coordination of Benefits (COB). • Knowledge of Third-Party Liability (TPL). • Advanced computer skills, particularly in Word and Excel, basic knowledge of database applications. • Strong communication skills both written and verbal. • Interpret and explain plan benefits, policies, procedures, and functions to Plan Participants, Internal and external customers. • Performs standard department metrics based on established goals and objectives. • Log appeals received into Excel, document claim notes and final determination for processor handling. • Develop a work in order receipt and review to determine the validity of complaint. • Scan and send supporting documentation to HCI on edited codes for review and determination. • Receive HCI determination and respond by letter or process claim adjustment. • Review medical notes and plan documents to determine appeal outcome. • Write letters requesting information or explanation of payment issues. • Create appropriate and accurate acknowledgment and resolution letters. • Ensure all documentation received for a claim is imaged and documented appropriately. • Answer questions from customer service and processors to explain and/or clarify claim processing, plan document or denial logic. • Problem solves difficult appeals by researching online sources, plan documents, coding manuals, external resources to determine accurate processing of the claim. • Timely review of claims/appeals. • Remains professional when working with internal and external customers. • Collaborates internally with department areas to ensure system configuration meets medical policy guidelines and plan provisions. • Perform other duties as required. Qualifications • Strong understanding of CPT, CDT, HCPCS, Revenue, and ICD10 coding structures • Knowledge of Coordination of Benefits (COB) • Knowledge of Third-Party Liability (TPL) • Advanced computer skills, particularly in Word and Excel, basic knowledge of database applications • Strong communication skills both written and verbal • Good organizational skills with the ability to work well under pressure Apply tot his job