Job Description

MedBen has been in business more than 85 years

. We offer results-driven solutions through innovation in employee benefits and health plan management, fully supported by customized solutions and a dedicated team of people working for us.

Our governing values include flexibility, respect, empathy, and dependability to meet our mission "

To be the benefits partner that employers prefer.

"

Candidates should currently reside in Ohio.

JOB SUMMARY

This position is responsible for the review and processing of large claims and those that carry more financial risk. This position also coordinates claim review activities conducted by MedBen's cost containment vendor ("CCV") and other vendors. Finally, this position acts as liaison between MedBen and utilization review vendors and pharmacy benefit managers and facilitates medical review of prior-authorization requests, if necessary.

SPECIFIC DUTIES

Coordinates and supports all claim activities involving the CCV including monitoring claim batches and claims selected for review to ensure timely payment, obtaining additional information needed for reviews, reviewing CCV recommendations, preparation of Vendor Recommendation Forms for acceptance, reprocessing claims to release payment, and processing CCV fees for payment
Review and release claims in excess of the claims examiner's authorization limit
Review and adjudicate broaching specific claims, repriced transplant clams, life insurance claims, short-term disability claims including group email notifications as necessary
Prepare and distribute the weekly high priority provider pending claims report; monitor handling of these claims to ensure timeliness
Follow all renewal procedures to ensure timely payment of stop loss claims
Manually refer potential third party liability claims to subrogation vendor as needed
Correspond with utilization review vendors and update applicable systems with related data, including the data base for covered persons in case management
Provide case management status reports and information to applicable MedBen employees and clients
Correspond with pharmacy benefit managers regarding pre-authorization requests for prescription drugs, issues approval letters and update eligibility notes
Submit prior-authorization requests to the appropriate medical review firm and return decisions to the claims examiner for response
Monitor OVER2000 workbasket to ensure claims are not released without a discount or applicable reduction
Performs general clerical duties, including filing, maintaining records and general correspondence
Other duties as assigned

PREFERRED KNOWLEDGE, SKILLS, AND EXPERIENCE

High School Diploma or equivalent
Two years' experience in the health insurance industry, preferably in the claims or medical review areas, where benefit interpretation was demonstrated
Strong keyboarding skills and knowledge of Windows and Microsoft Office (Outlook, Word, Excel, Explorer)
Basic understanding of medical terminology and industry coding (e.g, CPT, HCPCS, ICD-10, RVS) preferred
Ability to read and interpret reference manuals and benefit documents
Professional and effective verbal, written, and interpersonal communication skills
Detail-oriented with ability to work independently with minimal supervision
Highly organized with the ability to handle a wide range of responsibilities and competing deadlines

SCHEDULE

Individual team member schedules vary in order to cover department hours of 7:00 am - 5:00 pm Monday - Friday. Due to high volume business need, this department has annual vacation blackout periods during the month of December and the last week in June.

MedBen is an equal opportunity employer, and we consider applicants for all positions without regard to race, color, religion, gender, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or disability, genetic information or any other legally protected status.

Job Type: Full-time

Benefits:

401(k) Dental insurance Employee assistance program Flexible spending account Health insurance Life insurance Paid time off Referral program Retirement plan Tuition reimbursement Vision insurance
Application Question(s):

Do you currently reside in Ohio?
Work Location: Remote