Allied Benefit Systems · 2 hours ago
Senior Claims Specialist-Product
United States
Full-time
Remote
Senior Level
$48K/yr - $60K/yr
5+ years expAllied Benefit Systems is seeking a Senior Claims Specialist-Product to utilize independent judgment in reviewing and analyzing medical, vision, and dental claims. The role involves ensuring compliance with customized plans and making determinations regarding claims payments or denials.
Health CareInsuranceWellness
Responsibilities
Read, analyze, understand, and ensure compliance with clients’ customized plans. (A plan may be hundreds of pages or more.)
Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto
Request, review and analyze any physician notes, hospital records or police reports
Interview claimants, physicians, hospitals and other third parties for additional information
Consult with other professionals such as attorneys, nurses, physicians and auditors who can offer additional evaluation of a claim
Independently review, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physicians and hospitals; and 3) fraud
Process claims in the QicLink System
Review, analyze and add applicable notes to the QicLink System
Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com
Review billed procedure and diagnosis codes on claims for billing irregularities
Review and analyze specific procedure and diagnosis codes for medical necessity
Determine whether claimant’s plan covers the claim submitted and how much money, if any, should be paid
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis. (On a yearly basis, responsible for determining claims payments totaling millions of dollars on behalf of Allied’s clients.)
Review Workflow Manager daily to document and release pended claims
Review Pended Claim Reports and close out pended claims for which no response has been received
Review Suspended Claim Reports and follow up on open issues
Process Adjustment Claims when necessary due to corrected claims as well as applying refunds in the QL system
Assist and support Assistant Claims Specialists and Claims Specialists as needed and when requested
Attend continuing education classes as required, including but not limited to HIPAA training
Performs other related duties as assigned
Qualification
Required
High School diploma or equivalent required
5 years of medical claims analysis, processing and adjudication experience (including dental and vision claims analysis) required
Applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-10 coding terminology
Applicants must demonstrate the desire to assist the Team with exceeding all established goals
Preferred
College degree preferred
Prior experience in Adjustment Processing is preferred
Benefits
Medical
Dental
Vision
Life & Disability Insurance
Generous Paid Time Off
Tuition Reimbursement
EAP
Technology Stipend
Company
Allied Benefit Systems
Allied offers insurance products, self-insurance solutions, custom insurance and healthcare solutions to the individuals and organizations.
501-1000 employees
Funding
Current Stage
Late StageTotal Funding
unknownKey Investors
Stone Point Capital
2021-02-18Private Equity
Leadership Team
D
Dina H. Tank
Senior Vice President of Sales, Western Region
Recent News
2025-06-04
2025-06-03
Company data provided by crunchbase