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Benefits Consultant 1
Ref No.: 18-12046
Location: Newark, Delaware
Start Date / End Date: 10/15/2018 to 04/14/2019
Duration:0-6 month(s)

Description/Comment:Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)

• Analyzes and approves routine claims that cannot be auto adjudicated. (*)
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process. (*)
• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
• Routes and triages complex claims to Senior Claim Benefits Specialist. (*)
• Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements. (*)
• May facilitate training when considered topic subject matter expert. (*)
• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor). (*)
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools). (*)
• Exhibits the following Claim Benefit Specialist Behaviors