Claims Technical Review Specialist

🕒 3 days ago

🏄 California – Remote

🏄 California – Remote

💵 $27 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

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Zenith American Solutions, Inc.

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1944

🛡️ Insurance

🏥 Healthcare

💼 Consulting

Insurance • Healthcare • Consulting

Zenith American Solutions, Inc. is a U. S. -based third‑party administrator (TPA) that manages employee benefit and pension plans—particularly Taft‑Hartley and union funds—providing health and welfare administration, claims processing, retirement plan processing, contribution accounting, payment solutions, cost containment, compliance/privacy services, and participant/provider/employer portals. The company combines benefits administration expertise with technology and security-focused services to support trustees, employers, fund professionals and millions of plan participants nationwide.

📋 Description

• Provides advanced technical review of all types of claims in accordance with Company guidelines • Performs technical review and analysis of all types of 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 • Processes refunds, voids, and overpayments, including related claim adjustments • 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

🎯 Requirements

• 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 • Computer proficiency including MS Office Tools and Applications

🏖️ Benefits

• Health insurance • Vision coverage • Dental coverage • 401(k) plan with company match • Paid time off (PTO) • Opportunities for growth